Obama, Public Differ on Diagnosis

Because politicians are sensitive to how quickly the window of opportunity can slam shut, they try to seize the moment and move quickly when they can. One cost of this strategy involves attempting to impose a remedy before the patient really understands the diagnosis.

That's one explanation for the problems President Obama's health reform initiative is now confronting.

The president accepts bipartisan expert analysis that our system is costly and inefficient because there's an enormous amount of waste -- perhaps as much as 30 percent -- when patients are provided with services that are less than optimal -- and sometimes seem totally inappropriate -- to deal with their problems. Getting rid of that waste means eliminating many tests, procedures and even visits with specialist physicians.

A provocative, but less than helpful, word to describe efforts to reduce such waste is rationing.

Many members of the public are fearful of this strategy because they view the problem differently. They believe the system needs to be fixed because people are being denied services they need that could allow them to lead healthier lives. Let's quickly stipulate here that this happens.

But data suggests those not getting what they need is a significantly smaller group than those receiving excessive care.

The contrasting perceptions have been repeatedly documented. Bridging them is an ongoing problem. Suffice to say that the experts, who spend ample time talking with one another, have done an inadequate job of educating the public. The media, which understandably finds stories of the uninsured denied needed care more compelling -- and easier to get to -- than those of the insured who are overserved, hasn't always helped.

Our president, who is nothing if not a deft communicator, attempts to avoid confronting these competing visions by carefully choosing his language, regularly reassuring voters that they'll receive the care they need (which he carefully does not italicize) while carefully avoiding any promise that they'll receive all the care they or their doctors want.

This was reasonably easy to do during the campaign when cost (to the government) was less of an issue, allowing a focus on making care more accessible to individuals. Recall the debate about whether the Obama or Clinton proposal more quickly approved universal coverage.
But governing requires greater specificity than politicking and record deficits inhibit generosity for new spending.

Another way of papering over the challenge is to carefully define waste. There's general agreement bloated administrative costs imposed by insurance and alleged big profits for insurers and drug firms should be slimmed. Reducing paperwork and duplication is a universal worthy goal, but that's a far different thing than construing an extra x-ray, pill or surgical procedure that doctor and patient want as unneeded.

This quest to limit profits and administrative costs lends support to a government-run plan like Medicare, which has low administrative costs, or a similar new public plan. The resulting debate generates a lot of heat, but ignores the fact that Medicare is on the brink of bankruptcy, already imposes limits on tests and procedures that are available (just as private insurers do) and is every bit as tolerant of inappropriate and expensive care as other coverage is.

The debate seems more partisan than it actually is. In reality there's a split within each party on the over-consumption issue. Experts within the Republican Party think that backing away from employer-provided coverage would force individuals to make more prudent economic decisions that would reduce over-consumption.

Among Democrats, few believe that market forces can do the job in this area where supply basically creates its own demand.

Those with less expertise in both parties prefer to argue that everyone can get anything they want if only forces of evil (viewed as capitalistic insurers and drug makers by one group and malpractice lawyers by the other) can be tamed.

In the past, reformers have opted for the ever-popular dessert plan which provides more coverage in the short run and balances it with a promise to somehow make the system more efficient (by providing less care) in the long run. The long-running debate about reducing Medicare's physician reimbursement suggests, were any added proof required, that the long run never quite arrives.

Today's debate seems to be the latest chapter in the contest between progressives who want to delegate the big decisions (like what tests and drugs are worth paying for) to disinterested experts and the populists who demand that the voters be provided with what they want at a price they can afford by lowering the boom on the big, powerful and profitable institutions who set prices. In past decades, they logic they now would apply to drug and insurance companies was directed toward railroads and banks.

Until now, the American people haven't found either approach totally satisfactory and their continued ambivalence will probably require yet another compromise that papers over the difference. That's what the centrists on Capitol Hill are groping toward.

(This case is made in greater detail at Centeredpolitics.com, where this piece was initially posted.)

Comments

[Ozarks]

If congress, mainly Baucus, and his Senate rule violation, in using the "Gang of Six" to eliminate the Demo majority in the Finance Committee, had met Obama's Aug 6th deadline then there would be something concrete discussion on the "diagnosis".

[Jim Jaffe - Huffpost Blogger]

unclear what the rule violation is or that the majority is somehow being thwarted here. at issue right now is where the majority is -- and that's partly because of disagreement about the diagnosis.

[propitiousmoment]

"the populists who demand that the voters be provided with what they want at a price they can afford by lowering the boom on the big, powerful and profitable institutions who set prices. In past decades, they logic they now would apply to drug and insurance companies was directed toward railroads and banks."

Wasn't that logic applied to railroads & banks by *progressives* in the early part of the 20th century? And didn't it work fine up until the repub deregulation orgy in the last 30 years or so?

Anyway, it seems to me that the progressives, who want to delegate to a disinterested expert, and the populists, who want to smack down big medicine, can both have their way. And in fact they should.

[Jim Jaffe - Huffpost Blogger]

I don't know how to distinguish big medicine from ordinary medicine. I do know that any serious effort to control costs will require some controls on what doctors are now ordering and being reimbursed for.

[Alexander2791]

like the control you place or advocate for the wall street bankers who have sucked out billions of our tax-payers money but have no control placed on their salary and remuneration. A strong public option will take care of your false choices.

[MegWe]

You have perfectly described what the President and most of the bills in consideration are going to do. Bravo!!! You get it!!!!

[MegWe]

You just contradicted yourself twice in this one passage. How can Medicare both limit tests and procedures AND be tolerant of inappropriate care at the same time? Make up your mind.
This article is far from enlightening. In fact it is pure BS.

[Jim Jaffe - Huffpost Blogger]

well, as they say somewhere, I report, you decide. sorry you found the piece less than enlightening. the fact is that medicare does impose limits on procedures that can be done and certain types of test. the other fact is that many, including me, believe the medicare standard is a whole lot looser than it ought to be. the result is medicare sometimes finds itself paying a lot for bad medicine.

[MegWe]

Medicare finds inslef paying for a lot of bad medicine because Doctors and hospitals practice defensive medicine, and our medical culture, aided by insurance companies have thrived financially in this environment.. I have been shepherding two elderly parents through their twilight years for a decade now, complete with all of the headaches of medical billing. NEVER was there any rationing on the part of medicare. Never did a doctor hesitate to order a test because medicare would not pay. Quite the contrary. I am sure the reimbursements were so generous that it was to their advantage to "milk the system." This is what we must fix. This is what the President is proposing. So, I would agree that medicare sometimes does pay a lot for bad medicine. Best practice, scientifically needs to be established if this system is going to be around for me and my husband in a decade when we reach the age of 65.