Not often do you see David Brooks and Paul Krugman in substantive agreement on anything, but they are today–on the need to contain health care costs and the gravity of the President’s effort to confront this problem head on. The immediate challenge is Medicare reform: the fee-for-service system, where doctors are paid by the procedures–tests and surgeries–they perform, rather than by the patients they treat (as they are at excellent, comprehensive health care facilities like the Mayo Clinic).
I’d guess the chances of actual, real world success of this legislation–in terms of better care and better budget numbers–are very much dependent on this aspect of the legislation. In fact, the sooner we have a universal system, for all Americans, which ends the ghettoization of the elderly and poor into Medicare and Medicaid, the better chance we have for health care efficiency and quality. But there are three interest groups standing in the way of that–the first, and most important, are Republicans who scream about rationing. The President raised this issue early on: should his grandmother, dying of cancer, been given a hip operation in the last months of her life? Obviously, we’re going to have to start making those sorts of decisions (at least, decisions about who should pay for the hip operation, and how much, if the patient and her family deem it necessary). Some will call that rationing; others might call it sanity.
In the midst of his usual, toxic blather about Barack Obama today, Charles Krauthammer raises a valid and inconvenient point for Democrats about another interest group:
When a neurosurgeon pays $200,000 a year for malpractice insurance before he even turns on the light in his office or hires his first nurse, who do you think pays? Patients, in higher doctor fees to cover the insurance.
And with jackpot justice that awards one claimant zillions while others get nothing — and one-third of everything goes to the lawyers — where do you think that money comes from? The insurance companies, which then pass it on to you in higher premiums.
But the greatest waste is the hidden cost of defensive medicine: tests and procedures that doctors order for no good reason other than to protect themselves from lawsuits. Every doctor knows, as I did when I practiced years ago, how much unnecessary medical cost is incurred with an eye not on medicine but on the law.
The third group, also inconvenient for Democrats, are those labor unions who negotiated gold-plated health care plans for their members and are utterly opposed to taxing those benefits above a certain level–$15,000 per year would be a good number. This is certainly understandable, but it is unsustainable in the long term. It places too great a burden on American companies trying to compete with corporations from other countries where the government pays for health care. It also blocks the possibility of a comprehensive reform of the entire system, like the one proposed in the Wyden-Bennet bill (yes, that again), where all Americans might eventually choose from the same array of options. And, in the short term, the money is needed to fund the Obama package.
The problem with trying to pass the sort of reform that Obama is attempting is that all these interest groups have to be challenged simultaneously–the doctors, lawyers, insurers, pharma and labor–and that is a near-impossible task in a democracy as mature and invested as ours. That is why the process seems so hairy and chaotic right now. It will take enormous skill to bring home a bill worth having. But as the President said on Wednesday, we’ve reached the point where the status quo is not an option.