It’s true: they did it. The Democrats managed to get the words “comparative effectiveness” into the stimulus bill, just as many conservatives warned, which means that the infrastructure for rationing Medicare is now in place. The idea is pretty simple: a national health board will determine the comparative effectiveness of different treatments for different ailments, and then… well… you know, recommend them, in that coercive way that government does.
In Tom Daschle’s book, he contemplated, in a footnote, the idea of using such a national health board to regulate private health care plans, by threatening to take away the tax deduction for plans that don’t use the correct comparative effectiveness treatments. So, yes, the government will pretty much be running the health care system at that point. Well, it will be to a greater extent than it already is.
And yet, and yet, and yet… I’ll say it. Comparative effectiveness is good. Controlling the spiraling-out-of-control, eat-us-alive costs of Medicare is good. I’ll even go so far as to say that greater limits on the tax deduction for health benefits are good, good, good.
And I’m not sure why I should say otherwise, as a conservative.
I seem to recall a bill, passed in 2001, called “No Child Left Behind”. One of the main parts of that bill, the part that just about every conservative actually liked, was the part where they tied new grants to literacy programs that used, yes, comparative effectiveness research. The main program that benefited from that requirement was Direct Instruction, which was and is so effective that skeptical teachers tend to think that the whole comparative effectiveness idea — really, any form of accountability tied to method — is a total sham cooked up by The Man. No, they’d rather stick to the tried-and-true method of continually trying out the next (expensive) educational panacea promoted by the (well-compensated) textbook reps at the big conventions (at nice hotels), and buying all new (expensive) books and all new methods (that require expensive retraining seminars, possibly at that same hotel next quarter) every five years or so, all of which is based on research paid for, of course, by the textbook reps.
Good thing our free-market health care system isn’t anything like that. What a waste that would be.
I exaggerate for rhetorical effect, of course; it’s my right. But there isn’t a more conservative sentiment than “that’s all well and good, but not on my dime.” So, why don’t we make the argument; or rather, why does one side make the argument in one case, and the other side make the argument in the other?
Well, teachers and publishers are a Democratic constituency, and doctors and Pharma reps are a Republican constituency, by and large. That may have something to do with it.
It makes you wonder.
(Thanks to John Hawkins for the inspiration.)
35 responses so far
1 Cavosie // Feb 20, 2009 at 6:50 am
Nice post.
2 BoilerMan // Feb 20, 2009 at 7:09 am
So, you’re saying that a small group of government employees will come up with better solutions than millions of independent doctors and patients (and, yes, pharma reps)? This group will not just “recommend”; they will be making policy. It is impossible for this to not become a politically-driven process.
If this works so well for textbooks, and now medicine, why not everything? Why not just have a group of 10 people decide the best of every type of consumer product and make recommendations? Let’s get rid of all of the advertising and marketing waste on everything and just let DC tell us what’s best. That’s the logical conclusion of your argument.
3 joemarier // Feb 20, 2009 at 7:23 am
Thanks, Cavosie.
Boilerman, that’s not the logical conclusion of my argument; at least I hope it isn’t. Keep in mind that it is tax dollars — yours and mine — at stake when it comes to the growth of Medicare, and yes, I do think that a small group of government employees MAY be able to make better decisions re: how to spend government money than a million self-interested doctors, patients, and pharma reps. Then again, they may not. But the idea of determining comparative effectiveness when it comes to government funding of activity is good. Hope that clarifies.
4 Chekote // Feb 20, 2009 at 7:37 am
“I do think that a small group of government employees MAY be able to make better decisions re: how to spend government money than a million self-interested doctors, patients, and pharma reps.” Anyone who believes that government makes better decisions than individuals, is not a conservative. As a matter of fact, this site is not conservative. That is why it is slowly dying.
5 Bulldoglover100 // Feb 20, 2009 at 7:54 am
Agree 100% Chekote
6 joemarier // Feb 20, 2009 at 8:27 am
Anyone who believes that government makes better decisions in any specific case whatsoever is not a conservative? I’m sorry, is Murray Rothbard the epitome of conservatism now? Why are we opposed to waste and lack of oversight in government contracting, but strangely tolerant of waste and lack of oversight in government health care? Good grief.
7 fact based // Feb 20, 2009 at 9:06 am
“The idea is pretty simple: a n
which of course is far better than
for profit health insurers who only make money if the deny large numbers of claims determine the “comparative effectiveness of different treatments for different ailments” (i.e how they can find a rationale for denying the claim) and then… well… you know, tell you what they will pay for (regardless of whether it is what your medical professional thinks) and only pay for that, in that coercive way that the insurance company does. ”
and as for the definition of someone that thinks govt makes better decisions in any specific case whatsoever….looking at citi, bankamerica, countrywide, lehman, bear, gm and chrysler. I would say the definiton of that person is rational.
If these guys were running the post office half the mail would wind up in the pacific ocean ….and most of the ret in the atlantic
8 fact based // Feb 20, 2009 at 9:10 am
The idea is pretty simple: a national health board will determine the comparative effectiveness of different treatments for different ailments, and then… well… you know, recommend them, in that coercive way that government does.
which of course is far better than
for profit health insurers who only make money if the deny large numbers of claims determine the “comparative effectiveness of different treatments for different ailments” (i.e how they can find a rationale for denying the claim) and then… well… you know, tell you what they will pay for (regardless of whether it is what your medical professional thinks) and only pay for that, in that coercive way that the insurance company does. ”
and as for the definition of someone that thinks govt makes better decisions in any specific case whatsoever….looking at citi, bankamerica, countrywide, lehman, bear, gm and chrysler. I would say the definiton of that person is rational.
If these guys were running the post office half the mail would wind up in the pacific ocean ….and most of the ret in the atlantic
9 sinz54 // Feb 20, 2009 at 9:12 am
The real issue here, is that any long-term health care reforms should NOT have been sneaked into this so-called “stimulus” bill. A stimulus package is supposed to be a short-term quick fix for an economy that has stumbled temporarily. It is NOT supposed to perform long-term social engineering of American society. This “Comparative Effectiveness” Board is a very vague concept. It could be very good (if it’s staffed by NIH doctors and scientists), or it could be very bad (if it’s staffed by bean-counters). It deserved full debate. It got none, along with the other social-engineering provisions in the “stimulus” package.
10 sinz54 // Feb 20, 2009 at 9:16 am
fact based: The ONLY ones who should be judging “comparative effectiveness” are scientists and board-certified doctors. Bureaucrats, politicians, and bean-counters should not get a vote. Consider my situation: I’m suffering from a life-shortening illness. I don’t care which treatments are CHEAPEST. I only care which treatments are going to prolong my life span. I’m not prepared to trade off years of my life for saving a few dollars. And I don’t think most other patients would either.
11 Chekote // Feb 20, 2009 at 10:09 am
Joe. Central to conservativism is the individualism. I am not saying your ideas are good or bad. They are not conservative. You probably consider yourself a conservative because you are pro-life. That’s the problem with this site. Too many people are trying to redefine conservatism as either just social issues or a little less government than the liberal want. Sorry. It doesn’t work for me.
12 sinz54 // Feb 20, 2009 at 10:25 am
Chekote: Is your definition of conservatism: “A little MORE government than the libertarians want”???
13 sinz54 // Feb 20, 2009 at 10:28 am
Chekote: Would you favor repealing the Pure Food and Drug Act, and thus abolishing the Food and Drug Administration (FDA)?
14 Chekote // Feb 20, 2009 at 10:33 am
sinz54. Here is the best definition of conservatism:
http://www.kirkcenter.org/kirk/ten-principles.html
Check out princinples 8 and 9.
15 dragonlady // Feb 20, 2009 at 12:00 pm
I can’t believe what I’m reading. Frum is basically saying the government is better poised to advocate medical treatments because they know best rather than the individual undergoing treatment. Bringing costs down in health care is a worthy goal, but this is not the way to do it. Conservatives need to put patients at the heart of the health care system, not drs, insurers, or the govt. I can accept some govt intervention into health care to ensure there are safety nets regarding coverage, but govt control of health care will bring us to socialism. The free market is best poised to bring down costs, not a board of faceless bureaucrats.
16 dragonlady // Feb 20, 2009 at 12:17 pm
What’s disappointing about this site is that Frum seems to chase the latest polling opinions on platitudes of univeral health care, global warming, education, etc with little overarching philosophy. Instead of trying to please everyone and in the end, pleasing no one, how about conservatives actually try to apply their principles to the times and come up with more compelling messages? Good politicans can help shape opinion–just look at our President. There may need to be some fundamental reassessments on our stances in certain issues but with this site, I can’t tell what Frum’s core is at all.
17 dendup // Feb 20, 2009 at 12:37 pm
Much of what is asserted by every slice of the political spectrum about heath care starts with some combination of a political angling and fear. If any of us were to design a health care system from scratch, I doubt any of us would come up with what we have. What are the benefits and costs of the small, medium and large roles of gov’t in health care? If we try to answer such a question without using emotionally and politically charged words, we might get somewhere. Otherwise we just talk past each other. As to Frum, he’s just throwing out what I think he intends to be provacative statements to get the ball rolling. Just ingore the man behind the curtain.
18 Chekote // Feb 20, 2009 at 2:12 pm
Well said, Dragonlady. Frum and Company here are not conservatives. They haven’t figured out their basic government philosophy and therefore they are just chasing polls as you said.
19 gblittle // Feb 20, 2009 at 2:54 pm
The last thing society needs is yet another bureaucratic office mandating their will on the public. The idea that government is all wise and can make healthcare decisions is laughable. Tom Daschle attempting to educate the public about healthcare is like Al Gore lecturing us about global warming. Both are politicians (and not very good at that), not men of science. Government already does run healthcare and is the primary reason why costs are so high. They already have formularies on what medications they will pay for, thus to an extent they already are making the decision who gets what drug. Government in healthcare, just look at the VA health system. Expand that to all Americans, no thank you! Now I do agree some drugs are expensive, but in the overall scheme of things drug costs contribute very little in the overall cost of healthcare. A room at the Ritz is cheaper than a room in many hospitals and thats only the beginning you still have to add all the other ancillary costs. Many patients are over medicated, over diagnosed and there is a long litany of reasons why which adds untold dollars to healthcare. There are problems with healthcare in this country but many have been created by the government, not the industry as a whole or single entity. If Im sick I want the doctor, hospital and myself making the decision regarding treatment options, not some political hack sitting in DC. (And to the other posters here, I too sometimes wonder if this is a conservative site. Some of the posters and articles I read just want to make my head explode)
20 sinz54 // Feb 20, 2009 at 3:41 pm
Chekote, principles are not the same thing as policies. Principles are timeless and relatively abstract, but policies have to deal with the gritty realities of the moment. I really would like to know if you think the Food and Drug Administration is doing such a poor job that it ought to be abolished. Do you truly think America would be better off without an FDA?
21 sinz54 // Feb 20, 2009 at 4:00 pm
gblittle: “If Im sick I want the doctor, hospital and myself making the decision regarding treatment options, not some political hack sitting in DC.” Do you have private health insurance? If so, your private insurer is already interfering with your treatment, through the insurer’s own bureaucracy. These days, every “managed care” insurer has an approved “prescription drug formulary.” That lists the drugs your insurer will reimburse you for, fully or partly. If your doctor prescribes you a drug that’s not on the list, he had better have a VERY good explanation for your insurer, or else your insurer will still refuse to reimburse you for that drug, and you’ll have to pay full price. (Which can be very expensive; I’ve gotten caught that way a couple of times.) And each insurer has their own drug formulary. So if you’ve been taking a prescription drug for a chronic illness, getting reimbursed for a prescription drug through one insurer, and you switch insurance carriers, your new insurer may refuse to pay for it and you’re out of luck. Here in Massachusetts about 12 years ago, Tufts Health Plan announced they would no longer reimburse for minimally sedating antihistamines, telling their members to use the over-the-counter sedating ones (like Benadryl) instead. (This was back at a time when all minimally sedating antihistamines required a prescription.) This was disastrous for allergy sufferers who must drive on the road, like salespeople or truck drivers. Sedating antihistamines can cause you to doze off at the wheel. But of course, that wasn’t Tufts’ problem. It took a major campaign by the states’ allergists and asthma specialists to persuade Tufts to change its mind. It would be nice if there were some national standards, created by a blue-ribbon team of scientists and board-certified physicians (NOT bureaucrats of either government or private insurance companies), to try to sort all this out. Without such national standards, conservative proposals for portability of coverage (which both Bush and McCain favored) become impractical.
22 Chekote // Feb 20, 2009 at 4:04 pm
sinz. Principles guide you through the problem. I am okay with the concept of the FDA. It makes sure that products on the market are safe. They don’t make choices for consumers. They don’t endorse products. It really quite different from what is being proposed here. Actually, the market would take care of bad products because people would stop buying stuff that makes you sick and sue the companies out of business. Markets always work if you leave them alone. Look at the Ponzi schemes that are coming to light. Thousands of regulations and regulatory examinations, yet they couldn’t ferret the crooks out. Do you know what did Maddoff and now Sandford in? The falling market increased the redemptions and not enough new investments came in to cover them. So, again, the markets work if you leave them alone.
23 Chekote // Feb 20, 2009 at 4:20 pm
sinz. Most of your grievances can be addressed through regulation. I am extremely happy with my healthcare. I go to the doctor I want. Take the medicine I want. I like my HSA account. I just wish we could bring the cost down. That’s it. How about malpractice insurance reform?
24 jrwmd // Feb 20, 2009 at 4:35 pm
My concern with government choosing which therapies work is that the decisions will be made by MDs who think they really know what works. Most medical advances come from doctors who think outside the normal therapeutic modalities. Total joint replacement came from a very unusual orthopaedic surgeon. The same is true for almost all medical advances. There is a reason that we do so well caring for the seriously ill in this country, why our cancer and heart disease survival rates are so high. We should want to promote innovation, not bureaucratic medical decision making.
jrwmd
25 joemarier // Feb 20, 2009 at 11:13 pm
As always, thanks for the various comments and conversations amongst yourselves. There are a lot of things in there I agree with; I’m a huge fan of HSAs and malpractice reform. I am working from problems to solutions, rather than from philosophy to solutions, dragonlady and chekote. But, I can find reasons to do that in conservative philosophy. My conservatism is not Kirk’s conservatism. Rather, my definition is Buckley’s, and Richard Weaver’s; a paradigm of essences, towards which the phenomenology of the world is in continuing approximation. The phenomenon that I’m looking at is our health care system, and the fact that we have elected, and have elected to continue, an irrational and semi-hidden third-party-payer system, that is and continues to be financially unsustainable at all levels, public and private. I’m trying to come up with a feasible approximation of a solution, and part of that solution is greater constraints on doctors spending what is quite often our money. Comparing treatment effectiveness will be a part of that, whether it be through the price mechanism and our own shopping… or someone else’s. Or both.
26 Chekote // Feb 21, 2009 at 6:27 am
“I am working from problems to solutions, rather than from philosophy to solutions, dragonlady and chekote.”
Then you are a technocrat. Political parties and movements are about governing philosophy. I have posted several times that you can’t mobilize people to vote, contribute and volunteer under the “whatever works” banner. Most of the healthcare dollars are spent in the last six month of a elderly person’s life. By denying care after a certain age is reached, will dramatically lower healthcare costs. Children with special needs require expensive care. Should we force everywonan to genetic testing while pregnant and if an abnormality is found, then force her to have an abortion? These measures will dramatically reduce cost and since you are not guided by principles and only interested in finding solutions, let’s start drafting the legislation.
27 joemarier // Feb 21, 2009 at 7:16 am
A technocrat? Perhaps, to some extent. It’s a process thing: I come up with a solution, but I do stress test it against my principles. Certainly, I would oppose both of your solutions on principle, and I recognize that that’s the main concern with a national health board: that its decisions will violate the natural law in various and egregious ways. What I’m not sure of is whether or not such a board will violate the natural law automatically, if it’s limited to determining comparative effectiveness.
28 Chekote // Feb 21, 2009 at 7:29 am
Joe. The federal government does not need to get set up another layer of bureacracy just to share best practices. That is already been done in the private sector. It is another waste of taxpayer’s money. Just like No Child Left Behind, Faith Intiatives and so on. It also oversteps the constitutional authority of the federal government. There I go again with my principles! If we want to bring down healthcare costs – and that’s really the problem – first, malpractice reform. Doctors over prescribe tests because they want to protect themselves against lawsuits. Put the consumer in charge by allowing people to buy insurance across state lines, allow people to form pools outside employment.
29 Chekote // Feb 21, 2009 at 8:20 am
Joe. Why do you consider yourself a conservative?
30 joemarier // Feb 21, 2009 at 9:00 am
All fine ideas, but keep in mind that I’m thinking primarily of plans that are currently run by the government, like Medicare, Medicaid, S-CHIP. All of those plans have less oversight than your average insurance plan, and more — what’s the phrase? Oh yes — waste, fraud, and abuse. Particularly Medicare, which can only be fixed by lowering the cash that goes out of it, or increasing the cash that goes into it. Period. I prefer the former, because that will enable people who want more than Medicare offers, to go private with the cash that they save — or even better, to opt out of Medicare entirely and take the cash. Do you see what I’m driving at yet?
I’m sorry that you continually doubt my conservatism. I’m not sure what I can say or write that will prove beyond a doubt that I do not intend to sell the movement downstream at the first opportunity. But, I’ll keep writing, and I hope you keep reading.
31 Chekote // Feb 21, 2009 at 9:37 am
So you are going to create another layer of bureacracy to make the current bureacracy more efficient. Sorry Joe but the focus should be how to get government out of healthcare instead of increasing its role. The reason I doubt your conservatism is because you never answer my questions: what makes you a conservative? Why should people vote for the Republican Party over the Dems? It seems to me that if we want to build a conservatism that can win we need to first define conservatism. We need to answer the question of why should people embrace conservatism instead of liberalism. If we can’t answer these two basic questions, we can’t build anything.
32 joemarier // Feb 21, 2009 at 11:36 am
Fair enough. The question of how I came to the convictions that I hold is pretty complex, because it deals with my personal history, professional background, religion, and so forth. I’ll probably try and work up an extended answer and put it on my personal blog, next time I get a chance. But I do come out as conservative on the world’s smallest political quiz, as bad a metric as that may be.
33 sinz54 // Feb 22, 2009 at 8:52 am
Chekote: The problem with leaving “best practices” entirely up to the public sector, is that each private insurer chooses its own set of best practices. And those vary over time. If you have a chronic illness, one day you may find that your new (or even existing) insurer won’t remburse you for the treatments you’ve been relying on for years. I personally fell into that trap. I changed insurers, and my new insurer wouldn’t pay for the medication I had been relying on for years, because it wasn’t in my new insurer’s preferred drug formulary. If the private insurance industry got together and formulated national *standards* for drug formularies (similar to how the railroad industry in the 19th century all agreed on one standard gauge), then this problem would not happen. But they are not doing that, as far as I know. And there’s no way to find out these things in advance from the insurer, until some bureaucrat lets you know in a curtly worded letter. In our country, the government does have a role in setting standards. There are building codes for construction. There are health and safety requirements for restaurants. Etc.
34 Chekote // Feb 22, 2009 at 12:25 pm
sinz. Building codes set a floor of safety. I am not against addressing the problemsn you mention via regulation. If you want to be in the health insurance business you need to provide some basic services to everyone. Look, you believe that bureaucrats are better than the private sector. Fine with me. I don’t. Government is always subject to corruption and pretty soon the healthcare providors that make the most substantial campaign contributions will, miracle of all miracle, be the ones who provide the best treatments according to the government. Wink. Wink.
35 gerrysh // Feb 23, 2009 at 9:25 am
It makes everyone wonder why you are on a “conservative” blog.
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