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What To Do If Obama's Health Care Reform Is Not Good Enough


If I were a deficit hawk, this would be my critique of the Obama administration: Entitlement reform is health care reform. But the health care reform that's been sketched out at 1600 Pennsylvania Avenue is not entitlement reform. The benefits of comparative effectiveness and health IT are speculative. And the budgetary situation is too dire to put our trust in speculative benefits. The administration -- and more than that, the Congress -- needs to get serious about the budget and cut health spending closer to the bone.

That means a public plan that can bargain with providers and achieve the 20-30 percent savings estimated by the Commonwealth Fund. That means a radical increase in the number of primary care providers -- be they doctors or physician's assistants -- and specific policies meant to dissuade medical students from choosing specialty professions.

But the actual critique of deficit hawks -- like this paper's editorial board -- has always confused me. They are probably right that the Obama administration is not going far enough. But their conclusion is not to do more. It's to do less.

"Health-care reform," they write, "will have to be an incremental process." Again, it's probably true, as a predictive matter, that health care reform will be an incremental process. That is why it is unlikely to sharply bend the cost curve. Pointing out that fact is important, I guess. It's a good day's work for a blogger. But if I were an influential editorial board with an abiding concern for the deficit, I'd think my muscle could be put in service of actually changing that fact.

(Graph credit: Congressional Budget Office)

By Ezra Klein  |  June 1, 2009; 9:00 AM ET
Categories:  Health Economics , Health Reform  
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"be they doctors or physician's assistants"

Or nurse practitioners! Don't sell 'em short!

Posted by: wingus | June 1, 2009 9:18 AM | Report abuse

hold on to what you believe,
even if it is just a handful of earth.
hold on to what you believe,
even if it is a tree that stands alone.

Posted by: jkaren | June 1, 2009 9:48 AM | Report abuse

Yeah, it’s a very piecemeal justification to jam into a sound bite. The reform that’s coming together partly looks like it’ll save money, partly looks like it’s trying to increase value (via QALY’s - Quality Adjusted Life Years - or whatever other vaguely morbid indicator you choose to use). Basically, you’re pitching the following:

• Healthcare IT will save money via connectivity/EHR’s (reduction in unnecessary advanced imaging tests, cath lab charges, etc.), but that has to go hand in hand w/some physician education. That’s got the best chance of day-one savings of actual dollars.
• Comparative effectiveness will save actual dollars but not on day one, and no one knows how much.
• Preventive medicine won’t really save lots of money-money so much as it’ll help with QALY and whereas it’ll help us to not have such embarrassingly low health outcomes compared to other industrialized nations, it won’t be cash money.
• Aggressive chronic disease management saves SOME money, and does also increase QALY’s (some interesting pilot programs have been underway with Medicare, who has the biggest stake in chronic disease w/about 20% of patients with 5 or more chronic conditions accounting for 2/3 of all Medicare costs) and can hold hands nicely with the initiatives for more PCP’s and the Medical Home. This area has lots of potential, but, as you say, lots of it is speculative.

I think I’d also wonder how/why big pharma has managed to stay out of the administrations cost-saving crosshairs. There’s money to be saved there by reining in wily PBM practices but maybe the administration is afraid that talk to cutting back big pharma looks too anti-innovative? Not sure.

In any case, it's an unwieldy argument and yeah, not one wholly about saving money.

Posted by: ThomasEN | June 1, 2009 12:07 PM | Report abuse


You are hitting really hard where it needs to be.

It is amazing that such a venerable institution like Washington Post with so much credibility and such a deep bench; but the only thing we find worthwhile is what is on blog posts of likes of Ezra. Why does WaPo publish useless front page op-eds like Robert Samuelson asking press is in tank of Obama or not? Can he not read your post and your articulation of the critic? Why do smart people like Samuelson and WaPo editorial board waste their time on 'meta-narratives' and fail to go to the heart of the problem? Indeed there are valid criticisms of Obama Health Plans, you are offering one of them. Why do people have to keep on digging 'blogs' for these purposes and why do main stream media (e.g. WaPo front page) not publish these important aspects? They just continue to assume that readers are dumb ass interested in 'topless Britney' and Obama's night in New York. People have moved on, but our media continues to fail us.

Your blog is one solace and please continue this hard hitting. You have a job man - to wake up all those ivory tower editorial type bright bulbs. Then only you will be done and rendered expired.

Posted by: umesh409 | June 1, 2009 1:54 PM | Report abuse

Incremental does not mean doing less, it means doing things faster. And the faster we start doing things, the sooner we can start cutting costs, and thus the greater value of the savings. Malpractice limits, increased numbers of doctors, negotiated drug prices, higher deductibles, means testing, starting age increases, effectiveness analysis...all of these can be achieved individually.

In the end, there needs to be some disincentive to the patient and doctor getting to spend as much as they want on care- because overtreatment is a real problem.

Posted by: staticvars | June 1, 2009 2:31 PM | Report abuse

We did the first incremental step - Medicare for the highest risk pool, us old fogies.

Now is the time for the next incremental step - Medicare for everybody else.

Then we can think of the next incremental step - reforming the practice of medicine.

Posted by: lensch | June 1, 2009 3:01 PM | Report abuse

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