The health care bill seems to be moving, inexorably, in its herky-jerky way, to passage in the US Senate. If it passes, then the art of reconciliation between the House and Senate health care bills will begin. Many aspects of the Senate bill are likely to carry the day after reconciliation. Therefore, the bill in the Senate, morphing behind closed doors as it continues to do, is still probably our best guess as to the future of American medicine.
On Decembe 15th, President Obama stated flatly of the Senate bill: “It is deficit neutral. It bends the cost curve. It covers 30 million Americans…” We should remember these statements in coming years, because they are so patently false. The falsehoods, distortions, and wishful thinking that have suffused the health care debate in 2009 have made this The Year of Living Dangerously for all citizens who get medical care in this country.
Let’s be very clear about a health care bill that extends coverage, provides massive subsidies, and creates many new bureaucracies that affect millions of people: it’s not deficit neutral. In fact, one of the most impressive things about both of the massive health care bills in Congress is how little they contain in terms of real ideas for cost control. It’s almost as if Congress, and OMB director Peter Orszag, have never even heard of any of the really good ideas out there for rolling back costs in health care.
There are lots of ways, good ways, to control costs without rationing care. For example, it’s widely acknowledged by many health care economists that one big driver for spending is that patients are shielded from the costs of their care. Because insurance premiums are taken directly out of wages, and because many policies are so all-inclusive as to have low (or zero) co-pays, patients simply have no idea how much they’re spending. Because health care is, in effect, “free” for many people, they use more health care than they need. Removing the distortions in work-associated health insurance coverage will inform patients about the real health care costs they are incurring, and patients will react by spending less.
Another really good way to drive down costs is to increase the number of primary care doctors that we have in this country. The way to do this is to increase the number of residency positions for training these doctors. Also, it will be necessary to reform reimbursement, to make the payments to primary care doctors and specialists more comparable – this can be done in a cost-neutral fashion, to be sure. We will reap big cost savings by expanding and improving primary care. If we have more primary care doctors out there, then people will get better preventive care, get sick less, and stay out of the hospital more.
Another obvious area for cost control is medical malpractice reform. Fear of lawsuits can drive up medical costs, because doctors spend so much money on unnecessary, “defensive” medical procedures. Defensive medicine does not make patients better, and may even make patients sicker, by exposing them to unnecessary procedures and risks. And we haven’t even talked about attacking the obesity epidemic in this country, which all by itself contributes to 10% of the costs of health care.
Added all up, a very conservative estimate says that we could reduce costs by 25% or more if all of these measures for cost control were enacted. Such measures would not require any rationing of care, would not result in massive government intervention, and certainly would not involve any Presidentially-appointed panels to decide which treatments Americans could have in any given year. If these measures were undertaken, we would retain excellent care in this country, but we would spend a lot less for it.
These ideas are the real stuff of cost control – the real “curve-benders”. And breathtakingly, none of these measures appears in either Congressional bill. To see these bills, one would think that nobody in Congress had read anything about cost control that’s been published over the past three decades. All of the really smart people and the really good ideas about reining in health care costs have been simply ignored. Pretty impressive.
This tells us that, no matter the rhetoric and hyperbole, these bills are not about cost control. These bills are about extension of government power. These bills are about providing transfer payments, via health care subsidies and insurance, to more than half of the voting population. These bills are about consolidating a permanent, redistributionist state. And for all patients and taxpayers in this country, these bills are dangerous.
Dr. Laura Niklason is a physician and professor of Anesthesia and Biomedical Engineering at Yale University.
