Sunday, July 19, 2009

What's the Big Issue in Health Care? Is it Health? Or is it Cost?

What's the Big Issue in health care? Is it health? Or is it cost? Those dueling questions were brought to mind watching "Meet the Press" this morning, as David Gregory interviewed, first HHS Secretary Kathleen Sebelius, and then second, Senate Minority Leader Mitch McConnell. The topic, of course, was Obamacare.

Along the way, they helped clarify the choices that the American people face on health care: Do we focus on the quality of medicine, or do we focus on the policy of health-care distribution?

In arguing for the administration's agenda, Sebelius said that "Thirty percent of tests don't make people any healthier." One's immediate reaction is, "Maybe, but how does she know which 30 percent of tests are ineffective?" One is reminded of the famous quip about advertising effectiveness, attributed to 19th-century department-store pioneer John Wanamaker: "They say that half of all advertising doesn't work. But nobody knows which half!"

Indeed. Who should we trust to tell us that one-third of medical tests aren't worth doing? Has the federal government earned our trust?

Sebelius went on to criticize "money that's misdirected." Well, again, who do we trust to make those decisions? Who do we trust to do the re-directing?

Advocates of Serious Medicine understand that priorities must be established, but if so, let's get a closer look at the prioritizers, and what their proposed priorities might be. Then, and only then, will we feel better about putting them in charge of anything. And the right priority--the prime directive of Serious Medicine--is heavy research on critical diseases and problems, with an eye toward victory over those diseases and problems. We might not be able to defeat death, but we sure as heck can defeat, say, liver disease. How can I be so confident? Because, as Steve Jobs reminded us earlier this year, you can always get a new liver. Cost, of course, is an issue, but that's argument for economies of scale, as opposed to rationing. Or I should say, the popular argument is on behalf of driving the cost down through mass production. Unfortunately, the dominant argument is rationing.

Then Gregory asked Sebelius about the swine-flu vaccine. And suddenly, the Health Secretary was all about Serious Medicine. Sounding fully briefed on the status of the pandemic around the world, she said that scientists were working hard on a vaccine, and hoped that it would be ready by October. Well, that's great. But how much will all this cost? A lot, I am sure--but all worth it. And that's the point. Serious Medicine costs money. But it's cheaper than dying.

Next up: McConnell, who said of Sebelius-types, "They don't seem to grant that we have the finest health care system in the world." He's right. But of course, to the bean-counters, the overriding issue is cost. All these Euro-influenced left-liberals share a style of thinking, a style of critiquing. And in their critique is a heavy element of anti-technological romanticism, if not Luddism. That is, sewn into this style of thinking is the sense that enough is enough, that we lose our soul if we rely too much on technology.

This anti-technological argument--masquerading as a health-care-cost-control argument--reminds me of the defense-reforming "neoliberal" Democrats of the 80s, such as Gary Hart and Pat Schroeder, who accused the Pentagon of building "gold-plated weapons." Well, they were sort of gold-plated, cost-wise, but that's the thing about technology--it's expensive, at least at first. Only after awhile does it tend to get cheap on a per-unit basis. But cheap upfront is not necessarily good. I can remember one discussion, from the mid-80s, when the topic was building lighter (i.e. less "gold-plated") tanks for the Army. To which one pro-technology defense expert said, "They expect us to fight in orchards." That is, to fight in places that weren't too rough, that wouldn't require too much horsepower to get around, against enemies who weren't too dangerous. You know, sort of like suburbia, as opposed to Kursk. Well, history shows that the big battles, the Kursks, are the ones that determine the fate of nations and empires. If you come to a battle overprepared, as in too much armor and technology, fine. But if you come to a battle undeprepared, not so fine. Less is more might work for aesthetics, but it does not work for technics.

And the same is true for medicine: Technology is a necessary, albeit not always sufficient condition for good health. The treatments have to work, of course, but the treatments have to exist, first. And somebody has to pay for it. McConnell recalled a recent visit to the M.D. Anderson Treatment and Cancer Center in Houston, where he said that people from 90 countries around the world come to Anderson. And why do they come? For the results, obviously. And so who decides which procedure to do, and which test to run? We can assume that it's the doctors and other clinicians making those decisions. The moment that docs at Anderson have to ask permission from some rationer in Washington DC is the moment that people from 90 countries will stop coming to Anderson. And such a rationing scheme would not only be a loss to the cause of fighting cancer, it would also be a loss to the Houston economy, and, by extension the economy of Texas and the USA overall.

As McConnell said, "We have a cost problem. We have an access problem. We do not have a quality problem." And as we have seen, quality is the key to the economy--you have to make something better than anyone else makes, be it a good or a service. Anderson is obviously a world-class medical facility. So do we want to restrict it--or expand it?

Interestingly, Sebelius tried to make the case that Obamacare would be good for the economy, but she expressed herself in terminology that skipped right past McConnell's argument. Speaking in the "Meet the Press" segment before McConnell, Sebelius said that "reform" of health care "may be the single most important issue to get our economy on track." Well, put me down as doubtful. I think that the fate of the economy, up or down, will be driven by taxes and spending and "cap and trade." But to the extent that health care and medicine are economic drivers, their potential is seen in M.D. Anderson, which competes with the world--and wins--not some plan to recreate the UK's National Health Service here in the US.

That's the economic component of Serious Medicine, which can be summed up in Gompers-meets-Bauhaus precision: "More is more."

No comments:

Post a Comment