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Obama, Public Differ on Diagnosis

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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.)