Comparative Pain
Would there be resistance to such a proposal? Of course. But compared to what?
Let’s start from the point of view of individual citizens. Yes, many current Medicare beneficiaries would be upset by any change to the status quo. We’re not talking about them, but about people who would be joining the system in say, ten years.
Most of us who are now approaching retirement age or are younger have spent our entire lives living with, and largely accepting, some constraints on our choice of doctor, if only through the limits imposed by preferred provider networks. Personally, not once since I was still young in the early 1980s have I ever been part of a health insurance plan that allowed me to choose any doctor I wanted without paying a financial penalty, and I’ve had what by the standards of the times has been “gold brick” coverage. Virtually the only people left in America who don’t face such restraints are current beneficiaries of fee-for-service Medicare. If the price younger Americans have to pay for preserving Medicare is that some of us will sometimes be forced to “go out of network” and pay more of our own money to receive care of unproven value, then that seems like a pretty reasonable price to pay.
This is especially evident when one considers competing policy proposals on the table, such as turning Medicare into a voucher programs that leaves of us responsible in old age for paying 70 percent of our own health-care costs, or seeing Medicare reimbursement rates reduced to the point that we can’t find a doctor who will treat us. This particular reform is also far more attractive for most of us, I dare say, than having to wait until age 67 before reaching any entitlement to Medicare. To those who disagree, we could offer a choice: Wait until you are, say, age 70 to apply for Medicare, and then you can get fee-for-service medicine covered under the program. Or you could start collecting from Medicare at age 62 so long as you agree to receive your care from a Medicare-certified, nonprofit, HMO.
We can also expect lots of opposition from well-heeled practitioners of for-profit medicine—all those cardiologists making a killing doing unnecessary stent operations, for example. And we’ll hear from many prestigious academic medical centers, an unfortunate number of which engage in massive amounts of overtreatment because they are dominated by specialists who look down their noses at people engaged in “mere” primary care or efforts to bring more science into the human organization of medicine.
Yet as difficult as these challenges will be, reformers are now armed with abundant, peer-reviewed proof of just how dangerous and wasteful fee-for-service medicine has become, and the public has begun to catch on as well. Ten years ago, for example, researchers were just beginning to document how the death toll of medical errors, hospital infections, and inappropriate treatment had conspired to make contact with the U.S. health-care system the third leading cause of death in the United States. Today, most Americans who have spent any time in a typical hospital trying to make sure a loved one gets her proper medicine on time knows firsthand the extent of routine system breakdown.
Some conservatives, no doubt, will instinctively align themselves with the forces of for-profit, fee-for-service medicine or be lured into doing so by heaps of campaign contributions. Many Democrats as well can be counted on to carry water for prestigious, but deeply wasteful and dangerous academic medical centers, which tend to be concentrated in Deep Blue zones like New York, Boston, and Los Angeles. So yes, enacting this proposal will not be easy.
But then, ask yourself again, compared to what? Both parties have already signed on to changes to Medicare that are hardly less radical, will be resisted by powerful interest groups, and risk the wrath of voters. Moreover, these proposals are not really solutions because they either shift the inflating cost of health care on individual Americans or because they cut reimbursement rates to providers to the point that Medicare is “saved” on paper, but in the real world has little value to elders who can’t find a doctor.
By contrast, this approach directly attacks the root problem, which is the waste and inefficiency caused by fee-for-service medicine. And as politically difficult as the road to this solution may be, it does give each side things it wants. It allows Democrats to rightly say that they will not cut benefits to Medicare recipients. And Democrats should also like that these nongovernmental organizations serving the Medicare population will have the freedom to do things liberals have long wanted Medicare itself to do, like bargain with drug companies for lower prices. We progressives must also realize, as many increasingly do, that one of the unintended consequences of Obamacare could be to teach a whole new generation that government destroys everything it touches in health care—unless, that is, we take credible steps to bend the cost curve on health care while improving its quality.
Meanwhile, the proposal allows Republicans to boast that it takes a lot of decision making out of the hands of unelected bureaucrats in the federal government and puts that power in the hands of private organizations that compete with each other for customers. Under this approach Medicare officials won’t have to figure out how to write regulations on what is and is not reimbursable by Medicare; they’ll be contracting out those details to nongovernmental organizations and simply holding them accountable for results, such as keeping a high percentage of their patients healthy and managing their conditions effectively.
Let me close by stressing the positive. America is still a rich and productive country. Unlike Europe or Japan, it has a comparatively youthful population and no real long-term debt crisis except the one caused by volumes of wasteful and dangerous fee-for-service medicine. So once again in our long history, Americans get to get their cake and eat, too. We can improve our health care while lowering its cost and, in the process, eliminate our long-term deficits and resume building for the future.
Yes, there is a solution to the health-care crisis. It starts with the comparatively limited step of making our existing high-quality, cost-effective, VA system available to all veterans and their families. It ends with all Americans wondering why we took so long to open our minds and open our hearts to the broader lessons of the VA’s quality revolution.
Notes
Preface to the Third Edition
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2. Cannon MF. VHA is not the way. nationalreview.com, March 6, 2006. http://www.cato.org/pub_display.php?pub_id=5847.
3. Congressional Budget Office. Long-Term Analysis of a Budget Proposal by Chairman Ryan. April 5, 2011. http://www.cbo.gov/ftpdocs/121xx/doc12128/04-05-Ryan_Letter.pdf.
4. New England Healthcare Institute. Waste and inefficiency in the U.S. healthcare system, clinical care: a comprehensive analysis in support of system-wide improvements. February 2008; Mahar M. The state of the nation’s health. Dartmouth Medicine, Spring 2007; Kelley R. Where can $700 billion in waste be cut annually from the U.S. healthcare system? Thomson Reuters, October 2009; McKinsey Global Institute. Accounting for the cost of U.S. health care: a new look at why Americans spend more. December 2008. www.mckinsey.com/mgi/publications/us_healthcare; Skinner J. Understanding prices and quantities in the U.S. health care system. Journal of Health Politics, Policy and Law advance publication, July 5, 2011. http://jhppl.dukejournals.org/cgi/rapidpdf/03616878-1302939v1.pdf.
5. Kohn L, Corrigan J, Donaldson M, eds. To Err Is Human: Building a Safer Health System. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine, National Academies Press; 1999.
6. Klevens RM, Edwards JR, Richards CL, et al. Estimating health care–associated infections and deaths in U.S. hospitals, 2002. Public Hlth Rep 2007;122:160–166.
7. For example, according to a widely cited study published in the New England Journal of Medicine, if the United States were to adopt a single-payer system similar to Canada’s, there would be administrative savings, but they would result in only a one-tim
e drop in the baseline of health-care spending of about 14 percent at a time when health-care inflation is galloping ahead in double digits year after year. Meanwhile, universal coverage would inflate effective demand for health care. Thus, until they concentrate on the waste, errors, and inefficiency of U.S. medical practice itself, the advocates of a “single-payer” solution will still be at a loss to say how the country could afford Medicare for everyone. Wool-handler S, Campbell T, Himmelstein DU. Costs of health care administration in the United States and Canada. Engl J Med 2003;349:768–775. http://www.pnhp.org/publications/nejmadmin.pdf.
8. CBO’s 2011 Long-term Budget Outlook, June 2011, Table 1-2, Projected Spending and Revenues Under CBO’s Long-Term Budget Scenarios (Alternative Fiscal Scenario). http://www.cbo.gov/ftpdocs/122xx/doc12212/06-21-Long-Term_Budget_Outlook.pdf.
9. Ibid.
10. Living Within Our Means and Investing in the Future: The President’s Plan for Economic Growth and Deficit Reduction. http://www.whitehouse.gov/sites/default/files/omb/budget/fy2012/assets/joint_committee_reportfact_sheet.pdf.
11. Obama’s Health Care Cuts Spread the Pain, AP. http://www.time.com/time/nation/article/0,8599,2094023,00.html.
12. Office of the Inspector General Department of Health and Human Services, Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf.
13. Reed K et al. HealthGrades, Patient Safety in American Hospitals Study, March 2011. http://www.healthgrades.com/business/img/HealthGradesPatientSafetyInAmericanHospitalsStudy2011.pdf.
14. Jain R et al. Veterans Affairs Initiative to Prevent Methicillin-Resistant Staphylococcus aureus Infections, New England Journal of Medicine, 364:1419–1430, April 14, 2011. http://www.nejm.org/toc/nejm/364/15/; Kevin S. Study Finds Drop in Deadly V.A. Hospital Infections, New York Times, April 13, 2011. http://www.nytimes.com/2011/04/14/health/14infections.html?_r=1&ref=todayspaper; Marshall A. First Do No Harm, Washington Monthly, March/April 2011. http://www.washingtonmonthly.com/features/2011/1103.allen.html.
15. Waldron H. Trends in Mortality Differentials and Life Expectancy for Male Social Security–Covered Workers, by Socioeconomic Status, Social Security Bulletin, 67:3, 2007. http://www.ssa.gov/policy/docs/ssb/v67n3/v67n3p1.pdf.
16. Kulkarni SC, Levin-Rector A, Ezzati M, Murray CJ. Falling behind: life expectancy in US counties from 2000 to 2007 in an international context. Population Health Metric June 15, 2011;9(1):16.
17. Neuman T, Cubanski J, et al. Raising the Age of Medicare Eligibility: A Fresh Look Following the Implementation of Health Reform, Kaiser Family Foundation, July 2011. http://www.kff.org/medicare/8169.cfm; Van de Water PN, Raising Medicare’s Eligibility Age Would Increase Overall Health Spending and Shift Costs to Seniors, States, and Employers, Center of Budget and Policy Priorities, August 23, 2011. http://www.cbpp.org/cms/?fa=view&id=3564.
18. Emanuel E, Liebman J. Cut Medicare, Help Patients, New York Times, August 22, 2011. http://www.nytimes.com/2011/08/23/opinion/cut-medicare-help-patients.html?pagewanted=1&_r=1&ref=opinion.
19. Baker L, Atlas SW, Christopher CA. Expanded use of imaging technology and the challenge of measuring value. Health Affairs November/December 2008, 27(6):1467–1478; Fazel R, Krumholz HM, Wang Y, et al. Exposure to low-dose ionizing radiation from medical imaging procedures. New England Journal of Medicine 2009;361:849?–857; Board on Radiation Effects Research, Health Risks from Exposures to Low Levels of Ionizing Radiation: BEIR VII, Phase 2. Washington, DC: National Academies Press; 2006.
20. Dafney, LS. How Do Hospitals Respond to Price Changes? NBER Working Paper No. 9972, September 2003. http://www.nber.org/papers/w9972.
21. Fisher E. Share Savings with Doctors, New York Times, June 18, 2009 [“Room for Debate” on-line forum]. http://roomfordebate.blogs.nytimes.com/2009/06/18/better-medical-care-for-less/.
22. Jones S. Friends like these, Washington Monthly, July/August 2011. http://www.washingtonmonthly.com/magazine/julyaugust_2011/features/friends_like_these030379.php?page=all&print=true.
23. Goldstein A. Test of Medicare costs did not save much money. Washington Post, June 1, 2011.
24. Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations, Proposed Rule, Centers for Medicare & Medicaid Services. Federal Registry, April 7, 2011. http://www.federalregister.gov/articles/2011/04/07/2011-7880/medicare-program-medicare-shared-savings-program-accountable-care-organizations.
25. Monopolies threaten health care cost controls, Fiscal Times, February 3, 2011.
26. Starfield B. Is US health really the best in the world? Journal of the American Medical Association 2000;284(4):483–485.
Introduction
1. Kohn L, et al. To Err Is Human; Preventing fatal medical errors. New York Times, December 1, 1999, p. 22a.
2. Chernew ME, Hirth RA, Cutler DM. Increased spending on health care: long-term implications for the nation. Health Affairs, September/October 2009; 28(5):1253–1255.
3. Cox M, Alm R. Time Well Spent: The Declining Real Cost of Living in America. 1997 Annual Report, Federal Reserve Bank of Dallas.
4. Blendon RJ, Benson JM. Americans’ views on health policy: a fifty-year historical perspective. Health Affairs 2001;20(2):39, Exhibit 5.
5. National Center for Health Statistics. Health, United States, 2008, with Chartbook on Trends in the Health of Americans. Hyattsville, MD: NCHS; 2009, Table 26. Life expectancy at birth, at 65 years of age, and at 75 years of age.
6. Bunker JP. The role of medical care in contributing to health improvements within societies. International Journal of Epidemiology 2001;30:1260–1263. http://ije.oxfordjournals.org/cgi/content/full/30/6/1260.
7. Cutler DM, et al. The value of medical spending in the United States, 1960–2000. New England Journal of Medicine 2006;355(9):920–927. http://content.nejm.org/cgi/content/full/355/9/920-R11. Numbers are adjusted to present value.
8. Boden WE, O’Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, et al. Optimal medical therapy with or without PCI for stable coronary disease. New England Journal of Medicine 2007;26;356(15):1503–16; Cecil WT, et al. A meta-analysis update: percutaneous coronary interventions. American Journal of Managed Care 2008;14(8):521–528.
9. Deyo RA. Back surgery—Who needs it? New England Journal of Medicine 2007;356:2239–2243.
10. For a useful summary of this sad chapter in American medicine, see Welch HG, Mogielnicki J. Presumed benefit: lessons from the American experience with marrow transplantation for breast cancer. British Medical Journal 2002;324:1088–1092.
11. Fisher ES, Bynum JP, Skinner JS. Slowing the growth of health care costs—lessons from regional variation. New England Journal of Medicine 2009;360:849–852. http://content.nejm.org/cgi/content/full/360/9/849.
12. New England Healthcare Institute. Waste and Inefficiency in the U.S. Healthcare System; Mahar M. The state of the nation’s health. Dartmouth Medicine, Spring 2007; Kelley R. Where can $700 billion in waste be cut annually?
13. World Health Organization: Core health indicators. http://www.who.int/countries/en/.
Chapter 1
1. Findlay S. Military medicine. U.S. News & World Report, June 15, 1992, p. 72.
2. Wolistein JB. Clinton’s Health-Care Plan for You: Cradle-to-Grave Slavery in The Dangers of Socialized Medicine. Fairfax, VA: Future of Freedom Foundation; 1994. http://www.amatecon.com/etext/dosm/dosm-ch04.html
3. Bauman RE. 70 Years of Federal Government Health Care: A Timely Look at the U.S. Department of Veterans Affairs. Cato Policy Analysis No. 207. http://www.cato.org/pubs/pas/pa207es.html.
4. Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the veterans affairs health care system on the quality of care. New England Journal of Medicine 348:22 (May 29, 2003):2218–2227. http://content.nejm.org/cgi/content/abstract/348/22/2218.
5. Kerr E, Gerzoff R, Krein S, Selby J, Piette J, et al. A comparison of diabetes care quality in the veterans health care system and commer
cial managed care. Annals of Internal Medicine 2004;141(4):272–281. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15313743.
6. Asch SM, McGlynn EA, Hogan MM, Hayward RA, Shekelle P, Rubenstein L, Keesey J, Adams J, Kerr EA. Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Annals of Internal Medicine 2004;141(12):938–945.
7. Selim AJ, Kazis LE, Rogers W, Qian S, Rothendler JA, Lee A, Ren XS, Haffer SC, Mardon R, Miller D, Spiro A 3rd, Selim BJ, Fincke BG. Risk-adjusted mortality as an indicator of outcomes: comparison of the Medicare Advantage Program with the Veterans’ Health Administration. Medical Care 2006;44(4):359–365. See also: Selim AJ, Berlowitz D, Kazis LE, Rogers W, Wright SM, Qian SX, et al. Comparison of health outcomes for male seniors in the Veterans Health Administration and Medicare Advantage plans. Health Serv Res 2010;45:376–396.
[PMID: 20050934].
8. Oliver A. The veterans health administration: an American success story? Milbank Quarterly 85:1 (January 2007):5–35. www.milbank.org/quarterly/8501feat.html, table 5.
9. Choi JC, Bakaeen FG, Huh J, Dao TK, LeMaire SA, Coselli JS, Chu D. Outcomes of coronary surgery at a veterans affairs hospital versus other hospitals. J Surg Res. 2009 Sep;156(1):150–154. Epub 2009 May 3.
10. Keating NL, Landrum MB, et al. Quality of care for older patients with cancer in the veterans health administration versus the private sector: a cohort study. Ann Intern Med June 7, 2011;154:727–736.
11. Edayathumangalam R. Veterans health administration compared to private sector for older cancer patients. Focus (Newsletter of the Harvard Medical, Dental, and Public Health Schools) August 14, 2011. http://www.focushms.com/features/veterans-health-administration-compared-to-private-sector-for-older-cancer-patients/.
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