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Limits on Healthcare with Obamacare

Goodman Blog, Jul 23, 2009, NCPA

Obama Administration officials are saying it in every way there is to say it and the mainstream media is not paying attention.

In his speech to the American Medical Association, President Obama said what White House health advisor Ezekiel Emanuel and Office of Management and Budget Director Peter Orszag have said in print some time ago. The only way to control health care costs is to get doctors to provide less care — fewer tests, fewer procedures, fewer everything. Of course, the Administration wants to eliminate only that care that is "unnecessary." But HMOs say the same thing.


Clearly the Administration does not consider doctors the best judge of what people need. The obvious end game: Washington will tell doctors how to practice medicine.

One method they have in mind: the power of the purse. The Administration is asking for independent authority to set reimbursement fees for all providers under Medicare. The easiest way to discourage "unnecessary care" is not to pay for it in the first place.

An example of what can be done is actually in legislation being written on Capitol Hill.  Buried somewhere in the 1,000 plus pages is a provision to severely limit what Medicare pays for CT and MRI scans performed in doctors' offices. This would force elderly patients, for example, to go to the hospital for their radiology — where there are often lengthy waits. Patients in rural areas who must travel long distances to get to hospital-based testing facilities may be discouraged from getting the tests done at all.

To assist in this effort, the Administration is proposing a new federal health board to decide whether health care services are "effective" or "appropriate." When he first advanced this idea in Critical, Obama health care guru, Tom Daschle, pointed to the British National Institute for Health and Clinical Excellence (NICE) as the model. NICE has adopted a rule of thumb that health expenditures are inappropriate if they involve spending more than $22,000 to save six months of life. As a result, British cancer patients do not have access to drugs that are routinely available in the United States. The World Health Organization (WHO) estimates that 25,000 British cancer patients die prematurely every year because of these restrictions.

If health care is to be rationed, what's the right way to do it?  Zeke Emanuel (who is also the brother of White House Chief of Staff Rahm Emanuel) wrote an entire article on this subject in the Lancet on January 31, 2009. Emanuel advocated allocating health resources in order to maximize collective life years. Suppose a 25-year-old and a 65-year-old have a life threatening disease. Since the 25-year-old has many more potential years of life ahead of him, he should receive preferential treatment, says Emanuel. He justifies denying care to elderly patients in the following way:

The complete lives system discriminates against older people…. Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years.

There's more. In a different article written more than 10 years ago for the Hastings Center Report, Emanuel said health services should not be guaranteed to "individuals who are irreversibly prevented from being or becoming participating citizens." He continues, "An obvious example is not guaranteeing health services to patients with dementia."

To anticipate a possible charge of hypocrisy or inconsistency, let me acknowledge that I have for some time advocated empowering a health care czar with the ability to negotiate with providers. It is an idea I have been working on with former Medicare/Medicaid director Mark McClellan and many others — on the left and the right.  Under our proposal doctors, hospitals and other providers would be freed to approach Medicare with offers to repackage and reprice their services so long as these offers promise to lower Medicare's costs and improve patient care.

Our proposal to liberate the supply side of the health care marketplace is the exact opposite of the Administration's desire to control doctors by using the purchasing power of the federal government to tell them how to practice medicine, however.