Cancel the Code Blue

Friday, October 9, 2009

President Obama and the Democratic Congress repeat a mantra so often that it has become a truism: America’s health care system is a scandalous failure, and it is absolutely urgent that we fix it now. The mainstream media nod their agreement, yet the polls tell us something else: 80 percent of Americans say they are satisfied with the quality of their health care. In fact, the overwhelming majority of Americans, about three-fourths, are happy with their current health care coverage.

Why, then, does a savvy politician like Obama believe he has to push for a radical overhaul of health care? Because the polls also show that the same majority of Americans who rate their own health care as satisfactory join the critics when questioned about the “quality of the system” as an abstract whole. It is this unacknowledged inconsistency of American opinion that gives Obama the opening to press for what is, at heart, a plan for government-run health care.

Perhaps it would help if we paused to consider the greatest consequence of Obama Care: rationed or restricted access to doctors, therapies, and care. You need look no further than other nations with the governmentcentralized health systems that our president and Congress are intent on emulating. Under Obama Care, access is sure to be reduced in six major ways.

  • One: Less access to timely health care, especially by trained specialists. Independent, peer-reviewed studies document that patients seeking care from physicians with specialty training—cardiologists, orthopedic surgeons, neurologists—must wait far longer for those services under government-run health systems.

    Patients in Canada and Britain wait months longer than American patients for knee- or hip-replacement surgery, cataract surgery, and radiation treatment. In fact, Canadian patients must wait weeks, months, or even more than a year just for a referral for such care.

    Even as Americans contemplate moving toward these sluggish systems, the Canadian and British governments are spending vast sums studying how to reduce their scandalous waiting lists.

  • Two: Less access to state-of-the-art drugs that are proven to cure serious diseases such as cancer. Americans—men and women, adults and children—consistently have the world’s best survival rates from cancer, both common and rare types.

    The documented superiority of the U.S. health care system for cancer outcomes is seen most dramatically when comparing U.S. survival rates to those of the most centralized systems, such as the governmentrun universal National Health System of Britain or Canada’s wholly government-controlled universal health care system. One critical factor is a lack of access in those systems to new drugs proven to prolong survival, and often even cure, these otherwise lethal diseases.

    Nils Wilking of Stockholm’s Karolinska Institute, author of a widely reported publication that compares international cancer survivals, recently explained that nearly half the improvement in cancer survival rates in the United States in the 1990s was due to the introduction of new oncology drugs. He wrote: “No country on the globe does as good a job overall as the United States. Thus, the U.S. government should focus on ensuring that all cancer patients receive timely care, rather than radically overhauling the current system.”

    Why are government-run systems so far behind in cancer therapies? The prestigious journal Nature Reviews recently noted that government price controls were key to the lag in availability of cancer-fighting drugs in Europe. Of the seventy-one drugs receiving marketing clearance both in the European Union and the United States between 2000 and 2005, 73 percent received approval first from the U.S. FDA. On average, the FDA approval came one year ahead of clearance by the European Medicines Agency. (To those who would charge the FDA with rushing its research, the truth is that both agencies have an identical mean approval time of 15.7 months.)

    Drug developers choose to submit their applications first in the United States because the lack of government price controls allows private companies to recoup and ultimately profit from their huge R&D investments.

  • Three: Less access to modern medical technologies that lead to earlier diagnoses, safer treatments, and better outcomes. Technological innovation has defined medical advancement. Scientists expect even more remarkable advances with the emergence of molecular biology in clinical care. The high value of medical technology has not been lost on the American public: 80 percent say that being able to get the most advanced tests, drugs, and medical procedures and equipment is “very important or “absolutely essential.”

    In stark contrast with the United States, countries with governmentcontrolled systems show severe deficiencies in medical technologies, both in restricted availability and in the use of antiquated versions that often function at substandard levels.

    Quality is not the only issue; quantity is one as well. Published data comparing the availability of magnetic resonance imaging (MRI) and computed tomography (CT) scanners in the United States with Canada and other members of the Organization for Economic Cooperation and Development (OECD) are striking. The gap between Canada and the United States is large—32 CT scanners per million people in the United States versus 11.3 per million in Canada and 27 MRIs per million people in the United States versus 5.5 in Canada.

    In the United Kingdom, the House of Commons recently reported a severe underuse of modern medical technologies in its sixty-year-old National Health System, lamenting that the British system is “slow to adopt and diffuse new technologies” resulting in its “lagging behind many other countries.”

    In Canada, a 2008 study found that the national health care system relies on old and outdated medical technologies for cancer care, diagnostic services, cardiovascular care, neurology, urology, genetics, and general hospital and surgical services. According to the Fraser Institute’s annual Waiting Your Turn report, the median wait times in 2007 for Canada as a whole were 4.8 weeks for a CT scan, 10.1 weeks for an MRI, and 3.9 weeks for an ultrasound.

  • Four: Less choice of doctor and treatments. We don’t have to look outside the United States to understand how choice is weakened when government controls the system. In a 2006 report from the nonprofit Center for Studying Health System Change, nearly half of all doctors polled in the United States said they had stopped accepting or limited the number of new Medicaid patients. Why they are doing so is no mystery. When government dictates prices on services, those services become unavailable. And because of inappropriate government dictates on medical care coverage, it is the patient who suffers. Directly or indirectly, choice becomes limited and health care becomes rationed.

    The Obama administration sounds much like the United Kingdom’s House of Commons task force, which recommended “techniques for determining the cost-effectiveness of new technologies” with “nationally approved standards for the commissioning of new technologies.” Obama has plans for a Federal Health Board to set “evidence-based standards” to measure the benefits of insurance and quality for medical procedures, as well as federally directed health information-technology standards, rather than allowing private sector innovation to discover what works best in a competitive marketplace.

    Obama Care is likely to sacrifice another key differentiator of our medical care: the excellence of the American physician. As our government dominates insurers, will the best and the brightest continue to endure the years of training and sacrifices for a career in medicine? Will they want to pursue a career in which wages are defined by government and in which medically naive government employees with the sole mission of lowering costs dictate care options to physicians and their patients?

  • Five: Less access to choice of coverage. The administration’s proposal is expected to include a “public option” for insurance for those ineligible for Medicare, Medicaid, SCHIP, or other government health insurance plans. This new option would actually reduce access and choice of health insurance coverage to Americans, even though there would be no requirement to drop current private coverage.

    Why? An effect known as “crowd-out,” in which expanding public insurance mainly crowds out private coverage rather than providing coverage to the uninsured.

    Jonathan Gruber, an economics professor at the Massachusetts Institute of Technology, illustrated crowd-out in a 2007 National Bureau of Economic Research report showing that the number of the privately insured falls by about 60 percent as much as the number of publicly insured rises (and is much larger when familywide effects of eligibility are considered). Crowd-out is more likely to be seen among people with moderate incomes who have greater access to employer coverage or the ability to pay for it or both.

    The Robert Wood Johnson Foundation showed that crowd-out raises the costs of expanding coverage. Moreover, Lara Shore-Sheppard, an associate professor of economics at Williams College, reports that public health insurance expansions increase the likelihood that small businesses will limit their coverage.

    There are other reasons Americans should care about the crowding out of private insurance. Even though public coverage is meant to reduce insurance costs, costs to the government (meaning the taxpayer) end up increasing dramatically. For example, just seven months after Hawaii offered the only statewide universal child health-care insurance program in the country, the state had to end it. Public funds had essentially replaced the private coverage that children already had; more than 80 percent of those taking up the state health insurance were already covered by private insurance.

    The Obama administration plans to devise a federal board to determine “appropriate” insurance benefits for Americans. Government bureaucrats will decide, and then mandate, what insurance must cover. Yet government-defined insurance mandates are themselves a primary cause of expensive health insurance. Similar mandates requiring specific benefits have grown from a handful in the 1960s to around two thousand at present, according to the Council for Affordable Health Insurance, and those mandated benefits increase the cost of basic health coverage 20–50 percent, depending on the state.

    Why should all Americans be forced by their government to pay for benefits many don’t want or value, including massage therapy, acupuncture, in vitro fertilization, and chiropractic care? Yet as government insurance becomes more dominant and crowd-out weakens private coverage, it will become even easier for politicians to add mandates to what they consider necessary coverage for our families.

  • Six: Less access to the leading innovators and innovations in health care. By virtually all accounts, the vast majority of the world’s health care innovation springs from the U.S. health care system, whether judged by the number of clinical trials, the sources of the most important medical advances in recent history, the number of patents, the number of scientific journal publications, or the roster of Nobel Prize winners. But this American excellence would be at risk under government-centralized health care.

    First, access to innovative care would be stifled under centralized government oversight. This unprecedented intervention, interposing bureaucrats whose goal is reining in costs directly between doctors and patients, is openly intended to limit choices on new diagnostic methods and recently developed treatments.

    Second, heavy-handed government has been shown to stifle innovation in medicines. Just a decade ago, more than two-thirds of all drug research was conducted in Europe. Now 60 percent is conducted in the United States. In 1998–2002 there were only forty-four new drugs launched in Europe, where government-dominated health care systems dictate prices, compared to eighty-five in the United States.

    Third, with government as the overriding, dominant payer to doctors, the already announced plan to shift payments from highly trained specialists to family physicians and other generalists will undoubtedly dissuade many of the best and brightest—the source of those vaunted medical innovations—from pursuing rigorous subspecialty fields.

    Americans, repeatedly lectured about our health care system, are hearing from the administration that this is a rescue of the highest priority, a full-scale emergency, code blue, that must be implemented stat, as my medical colleagues say. But a better response is not haste but careful deliberation. Costly, sweeping changes could force Americans to lose precious access to what most of the world envies. Who better than doctors to remind our government of the phrase primum non nocere: first, do no harm?