Will Health Care Reform Spawn the Next Great Culture War?

When I turn 35 I will have my first mammogram.

In the United States, mammography is recommended for breast cancer screening every one to two years beginning at age 40.  The best available evidence suggests that mammography screening among women aged 40 to 74 reduces breast cancer mortality.

But due to a few minor risk factors, three doctors have suggested I undergo a baseline mammogram at 35. I’m not thrilled with the idea of having a technician I’ve never met manipulate my breasts into squishing position, but being felt up and flattened out sounds a lot better than being dead, so I’ll take my chances.

Of women who receive annual screening mammography beginning at age 40, six out of 10,000 over a decade will have their lives saved.  Breast cancer will be detected and cured in many more, but regular mammograms will only make a life or death difference for six of every 10,000 women in that group.  Mammograms are of extremely high value to those women and their families, but don’t offer much bang for the buck when it comes to the other 9,994 women.

And wringing more bang from every health care buck is reason enough for Canadian and British recommendations that women wait until age 50 to begin receiving screening mammographies.  In these countries where cost-effectiveness studies influence health policy and medical practice, six saved lives aren’t worth the substantial costs associated with all those extra mammograms and the false positives they sometimes produce.

Canadian women are offered routine mammograms every two years, but only from age 50-69 because “evidence is not conclusive” that routine mammograms benefit younger and older women.  Doctors have some leeway with regard to high risk patients.

In the United Kingdom, mammograms are recommended every three years beginning some time between age 50 and 53.  Based on guidelines developed by the Orwellian-named NICE (National Institute for Clinical Excellence), the National Health Service insists that for women under 40, “mammograms should only be used as part of clinical trials into screening and that they shouldn’t be used under age 30 at all.”  According to NICE, “Healthcare professionals should respond to women who present with concerns but should not, in most instances, actively seek to identify women with a family history of breast cancer.”

It is hardly shocking that the breast cancer mortality is 9 percent higher in Canada and 88 percent higher in the United Kingdom.  Nine of 10 middle-aged American women (89 percent) have had a mammogram, compared to less than three-fourths of Canadians (72 percent).  And British and Canadian patients wait for care about twice as long as Americans.

There are indeed valid criticisms American health care, but one area in which we excel is that we don’t base guidelines for care on cost-utility analysis. That’s why the U.S. ranks first in providing the “right care” for a given condition and has the best survival rate for breast cancer.

Obamacare may force Americans to give up those bragging rights.

The “right care” may soon be defined in part by how much that care costs. Health care reformers acknowledge the impossibility of implementing universal health care without introducing cost containment measures, and Democrats are enamored with a method used by the British called “comparative effectiveness research” (CER.)

AARP CEO and CER proponent Bill Novelli describes comparative effectiveness research as “a wonky term that just means giving doctors and patients the ability to compare different kinds of treatments to find out which one works best for which patient.”  And at its best, that’s just what CER does.  CER is not inherently bad.  For example, it can help doctors cut through seductive pharmaceutical advertising to identify older, less commonly prescribed drugs that are just as effective as newer, more expensive ones.

But with CER, the devil is in the details.

CER can lead to one-size-fits-all medicine and encourages a purely analytical approach to care that is not always beneficial to the patient. The mythical average patient overshadows the individual patient, leaving most of us with about as many options as a public school cafeteria at lunchtime.

And in the UK, NICE includes cost as a determining factor in the comparative effectiveness studies that inform clinical guidelines.  Determinations about whether citizens will have access to drugs, tests, and procedures are based on cost per quality of life year (QALY.)

The QALY score is a fairly crude metric that takes into account both the number and quality of years a medical intervention is expected to add to a patient’s life.  Here’s the upshot of using QALYs to determine cost effectiveness:

On the QALY scale, 0 means you’re dead, 1 means you’re in perfect health, and varying levels of debility fall in between. Imagine two groups of people, one with a QALY of 1 and the other with a score of 0.5. An expensive technology brings a year of life to both groups. But in the second, that technology would be counted as having provided only six months, and thus be twice as expensive. It may be deemed too costly for that patient group.

The older you are, the sicker you are, the more disabled you are, the less cost effective it is to treat you.  And if the cost per QALY of a medical intervention you need exceeds £20-30,000 (around $32,000 – 48,000), you’re out of luck.  Drugs, particularly end-of-life treatments, are routinely rejected for use due to poor cost-effectiveness.  And screening tests, like the mammograms American women take for granted, are severely restricted to ensure expenditures remain under the cost per QALY threshold.

Liberal proponents of health care reform accuse conservatives of paranoia and fear mongering about health care rationing.  Critics of CER are demonized as extremist spewers of far right talking points who don’t care about improving clinical effectiveness.  Surely a uniquely American flavor of a CER board would never become as proscriptive as NICE.

But it seems conservative anxiety (and perhaps a bit of healthy paranoia) is more than warranted by Washington Democrats singing the praises of cost-cutting comparative effectiveness studies.  Bear with me while I review some of the health care rationing talk in CER clothing coming from inside the beltway.

The stage for CER to become a significant component of health care reform was set when President Obama’s stimulus bill passed with a $1.1 billion appropriation for CER.  In April, Senate Minority Whip Jon Kyl (R-AZ) introduced a budget amendment to ensure that CER would be used appropriately:

Statement of Purpose:
To protect all patients by prohibiting the use of data obtained from comparative effectiveness research to deny coverage of items or services under Federal health care programs and to ensure that comparative effectiveness research accounts for advancements in genomics and personalized medicine, the unique needs of health disparity populations, and differences in the treatment response and the treatment preferences of patients.

The amendment was defeated 54-44.

Last week, members of the New Democrat Coalition proposed HR 2505, a bill to establish a new government bureaucracy called the Health Care Comparative Effectiveness Research Institute.  The Institute would prioritize research based on both clinical and economic factors, including “the effect or potential for an effect on health expenditures associated with a health condition or the use of a particular medical treatment, service, or item.”  This would not be a problem if there were safeguards to ensure that best practices are not interpreted to mean the least expensive practices.

Officials at National Institutes of Health (NIH) recently announced a stimulus-funded initiative to integrate cost-effectiveness into clinical research.   “Cost-effectiveness research will provide accurate and objective information to guide future policies that support the allocation of health resources for the treatment of acute and chronic diseases across the lifespan,” according to the call for proposals.

Back at the Whitehouse, President Obama has been paying lip service to the clinical benefits of CER.  At the same time, he recently lamented that “the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill … there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place.”  That, he explained, was part of the need for “some independent group that can give you guidance” on the ethical dilemmas involved with rationing end-of-life care.

During her Senate confirmation process, Secretary of HHS Kathleen Sebelius declined to voice her support for prohibiting the use of comparative effectiveness data to withhold care from patients. Her ideas echo those of Tom Daschle, the tax-dodging health policy wonk who wrote in his book that the U.S. “won’t be able to make a significant dent in health-care spending without getting into the nitty-gritty of which treatments are the most clinically valuable and cost effective.”

Then there’s Peter Orszag, Obama’s director of the Office of Management and Budget and a major player in crafting health care reform.  For the most part, Orszag’s commentary on CER has been limited to lauding its ability to improve patient care while reducing waste.  But when asked a few months ago if the Obama administration has a position on empowering the CER board to make reimbursement decisions, Orszag said, “Not at this point.”

But perhaps of greatest concern is a January House report that included the following statement on CER funding:

By knowing what works best and presenting this information more broadly to patients and healthcare professionals, those items, procedures, and interventions that are most effective to prevent, control, and treat health conditions will be utilized, while those that are found to be less effective and in some cases, more expensive, will no longer be prescribed.

Sound familiar?  Cough, NICE, cough, ahem.

And as Jim DeMint explains, “CER is only one step in the Obama administration’s insidious plan to take over American health care … for our own good.”

But would CER really lead to health care rationing in the United States?  Of course.  That’s pretty much the point.  The debate is not about whether or not CER would be used for rationing, but rather, whether rationing is ethical and useful, and how far we’re willing to go to save a buck and level the economic playing field.

If health care reform shapes up as many Democrats anticipate, CER Institute guidelines will initially apply to the public insurance option expected to be the centerpiece of the Democrats’ proposal. But eventually they would slide down the slippery slope into the private sector. A public insurance option would also ride roughshod over the already anemic competition among overregulated private sector insurers, making the survival of private insurance unlikely.  As in the United Kingdom, recommendations will become rules and suggestions will become mandates in order to contain the costs of universal coverage.

To what extent will this result in government control of the doctor-patient relationship?  Ultimately, a bureaucratic board will determine when, how, and whether or not you and your family receive care.

Comparative effectiveness research will no longer be just a political hot potato; it will be the basis for the next great American culture war.  Instead of clashing over God, guns, and gays, we’ll battle over the monetary value of human life, the sanctity of doctor-patient relationships, the right to medical self-determination, and my favorite hot button issue, the duty to die.

Would cases like Terry Schiavo’s be decided based on financial considerations?

Where will fetuses fall on the QALY scale?  How about the elderly or people with Down syndrome?  Will they automatically receive limited treatment due to limited resources?

Will smokers be eligible for chemotherapy?  Will overweight people have restrictions placed on cardiac care?  Will we feel differently about those decisions when we’re footing the bill for everyone?

And you thought the abortion debate was contentious.

Obviously these questions address the most extreme examples of what could happen if we continue on our current path toward universal health care.  But government efforts at cost containment through CER may push us toward debating these issues sooner than we think.  Hopefully we’ll never see the day when questions like these go beyond an academic exercise.

Meanwhile, I’ll be saving up for a date with a mammography machine in one of those thriving medical tourism meccas.  I hear Costa Rica is a breathtaking location for a 35th birthday celebration.

Comments

9 Responses to “Will Health Care Reform Spawn the Next Great Culture War?”

  1. Rob Taylor on May 27th, 2009 7:30 am

    88%!?!?! England truly is a cesspool. This is basically murder by the state of women without the means to flee England and find a good doctor. That country can’t collapse fast enough if you ask me.

  2. Will Health Care Reform Spawn the Next Great Culture War in America? - Smart Girl Nation on May 27th, 2009 10:11 pm

    [...] article originally appeared on JennQPublic.com. Tags: Barack Obama, breast cancer, CER, Comparative Effectiveness Research, health care, health [...]

  3. sally on May 31st, 2009 9:54 am

    very scary and infuriating. one of the most infuriating things is that the average person has no idea the impact Obama’s actions will have on their future. someone made the statement to me the other day that Obama really hadn’t done that much yet. people have no idea the speed at which he has attacked major issues. if it isn’t on the Today show, most people don’t know anything about it.

  4. Jenn Q. Public on May 31st, 2009 9:21 pm

    Sally, you’re absolutely right. I know people who get all their news from The Daily Show and The Colbert Report! They are the same people who voted for Obama partly because the ideal of universal health care sounds so noble and righteous. But it really takes willful ignorance to continue believing that the proverbial free lunch exists. We will all pay, some in the form of extra taxes, all of us in the quality and availability of care.

  5. Eclectic Radical on June 1st, 2009 4:14 am

    I blame the right for the obsession with health care costs by the advocates of health care reform on the left. For years and years the response to every call for real health care reform is ‘but it will cost too much’, as if our current system were somehow cheap. So many on the left are searching for ways to make proposed reform cheaper, as a counterargument.

    Honestly, as a liberal advocate of health care reform, I’m rather disgusted with the current obsession with ‘cost.’ Quality health care is never going to be cheap. It will be more cost effective for taxpayers to subsidize health care in the place of several hundred competing insurance companies, because the principle behind insurance is shared cost and the tax base can share costs FAR more efficiently than multiple companies in competition with each other. There are also artificial costs inherent in the corporate health care system we currently possess that would be eliminated by a single-payer system or a non-profit system. But costs aren’t the real point.

    The real point is access to care. As a self-employed man without children I have the choice of paying for prohibitively priced private health care or going without health care and hoping I do not get dreadfully sick. I make enough to contribute my share to the household income, but not enough to pay for private health care. My girlfriend has health insurance through her job, but after a bad year in which she had to be hospitalized twice for completely unrelated issues, her health insurance is largely useless and she has had to pay large out of pocket costs for medication and co-payments which have had a serious impact on our finances. Were I to get seriously sick too, it would be a disaster. Less serious but more constant a problem, I am an epileptic and as a result I have to pay large out of pocket costs for medication without insurance, but cannot afford private insurance.

    Under the current system, we are screwed. My girlfriend’s coverage was insufficient to meet her medical needs when she actually got sick and I am uninsured and will remain so for the foreseeable future. We are not screwed because we are lazy bums, we are both working. We are screwed because the insurance offered by her employer is not what it should be and because I am self-employed.

    I would very happily pay more taxes to be able to see a doctor and not spend so much every year on seizure medication. I think more and more, as much as I hate to give the man credit for anything, that Ralph Nader is right and the real solution is the extension of Medicare to cover all Americans.

  6. Jenn Q. Public on June 1st, 2009 9:41 pm

    I don’t think focus on costs is inherently bad, but you’re right, it has grown into a nasty obsession. I don’t know (or really care) which side of the aisle the obsession came from, it just needs to stop so we can have realistic discussions about health care reform.

    Eclectic Radical wrote:

    As a self-employed man without children I have the choice of paying for prohibitively priced private health care or going without health care and hoping I do not get dreadfully sick.

    I am also self-employed, but I prioritize health insurance over non-essentials like vacations and tons of shoes and makeup. We all make choices. I have high deductible catastrophic insurance that doesn’t cover my annual exams, birth control, etc., but it is a financial planning tool that ensures my retirement accounts will be protected if I have a major health problem. It’s my choice to purchase that insurance, and my choice to work extra hours and take consulting gigs on the side to pay for it. Why should your tax money subsidize me if I’m capable of working my ass off to buy something I value? It’s not your job to give me peace of mind.

    I doubt you’re a lazy bum and I’m sure with a pre-existing condition insurance is extra expensive. That sucks big time. But sometimes being dealt a crappy hand means you have to work a little harder to get what you want. (Sorry, I know that sounds preachy, but I’m tired and don’t feel like rewording what I wrote.)

    Look, I don’t know your specific situation and what kind of disabilities you might be dealing with. But I know you spend time blogging and commenting every week. If insurance is important to you, stop giving away your writing (which is excellent) and grab yourself some freelance gigs to pay for it. Or, I hear there’s still big money in Internet porn. ;) But you’re not screwed because of your gf’s crappy insurance and your employment status, you just have a tougher time making ends meet.

    You want to pay more taxes to get what you want. I’d rather work more hours to get the same peace of mind.

    Oh, and let’s fix Medicare and find a way to fund it before we consider expanding the program to more people.

  7. Eclectic Radical on June 11th, 2009 9:48 am

    “I am also self-employed, but I prioritize health insurance over non-essentials like vacations and tons of shoes and makeup. We all make choices. I have high deductible catastrophic insurance that doesn’t cover my annual exams, birth control, etc., but it is a financial planning tool that ensures my retirement accounts will be protected if I have a major health problem. It’s my choice to purchase that insurance, and my choice to work extra hours and take consulting gigs on the side to pay for it. Why should your tax money subsidize me if I’m capable of working my ass off to buy something I value? It’s not your job to give me peace of mind.”

    I prioritize essentials like rent, food, clothing, health care expenses and utilities over everything else. When I am done with those prioritizations, I have nothing left for substantive health insurance and with an actual need to see a doctor and have regular lab work done to monitor my medication levels non-substantive health coverage would actually be a waste of money which would impede my ability to pay for my necessary health care expenses because I would be spending the money set aside for them on coverage that doesn’t pay for them.

    This is a philosophical argument neither of us can win, because we have a different set of philosophical commitments about certain principles.

    However, as for Medicare, I am always very interested in discussions of ‘fixing it’ and ‘figuring out how to pay for it.’ I am not certain it is ‘broken’ in a way that requires blatant ‘fixing’. Most Medicare recipients are far more satisfied with it than most holders of private insurance are with their own policies, and consumer studies bear this statement out. Someone is doing something right. At least one conservative Republican plan to ‘fix’ Medicare (CPR is the catchy abbreviation) involves breaking it beyond repair so the private sector can compete with it. This tends to suggest that the ‘problem’ with Medicare as most conservatives see it is that it is too much better than the private competition. The actual link to the write up of CPR by its creators is in my blog.

    As for paying for it, it is just a matter of prioritization. I consider Medicare to be more essential than subsidizing Hewlett-Packard’s efforts to fire more American workers and send American industry to China and Singapore or to fund a war in Iraq or Afghanistan. Clearly, many in Congress in BOTH parties disagree with me. The cost of the war in Iraq, as has been beaten to death my many liberal and independent writers (and even some disgruntled hard-line conservatives such as Ron Paul), would have ‘saved’ Medicare. This is just one example, and I am not trying to foist an opinion about the Iraq War (pro or con) onto you. I am simply making a statement about priorities.

  8. The 9 Most Asinine Statements by Vile Harpy Joy Behar : Jenn Q. Public on December 24th, 2010 3:01 am

    [...] Breast cancer mortality rates are 88 percent higher in the UK than they are in the United States, and British patients wait twice as long to see a specialist. So why wouldn’t Joy “The Brain” Behar want a heaping serving of what they’re having? [...]

  9. The 9 Most Asinine Statements by Vile Harpy Joy Behar : Jenn Q. Public on December 24th, 2010 3:01 am

    [...] Breast cancer mortality rates are 88 percent higher in the UK than they are in the United States, and British patients wait twice as long to see a specialist. So why wouldn’t Joy “The Brain” Behar want a heaping serving of what they’re having? [...]

Leave a Reply