Ah, it seems so easy.
We all know that there’s waste in health care. We all know that there are unnecessary tests and treatments, and that if we could figure out what they are and eliminate them, health care costs would lower and we would all benefit.
The problem is that it’s only ex post facto that we can know in each individual case what the unnecessary procedures might have been—and sometimes not even then. The rest of it is mere statistics, and often “garbage in, garbage out” ones at that.
If, for example, we know that back pain is common but that only a tiny percentage of cases will ever need surgery and the rest will heal on their own, how does a doctor decide what tests to run in order to find out which category Patient A fails into? I speak of back pain because it’s something with which I’m all too familiar, having hurt my back fairly severely nearly two decades ago. I never had surgery, but I didn’t lack for opinions that said I should. The only problem (well, it wasn’t the only problem, but it was one of the many problems) was that each doctor I went to over about a twelve-year period recommended a different type of surgery, and gave me different odds for post-surgical improvement.
Since all of these doctors had very fine reputations it was sobering, to say the least, to hear their disagreement. None of them was able to explain all of my symptoms, some of which were puzzling and rare. Some suggested that, without surgery, I’d continue to become worse. A few said that without surgery I was likely to improve. And initially, when I’d first been injured, the highly-recommended doctor I visited had said it was only a muscle strain and did not order an MRI until eight months of fairly severe pain had gone unmitigated, and my symptoms had actually worsened from the exercises he had me doing when he didn’t realize I had a severely herniated disc.
None of this inspired confidence, and so I postponed the decision to have surgery. And postponed it and postponed it. Then, as the years wore on, my symptoms did in fact improve. Does this mean I was correct in refusing surgery? Hardly; maybe I’d have been even better if I’d had it. Perhaps I could have gained many pain-free years during which I suffered instead, as well as removing some limitations I still face.
But perhaps not. I will never know, and I’m at peace with that. I did the best I could and the doctors did the best they could.
I’m the sort of person who does research, and so even way back then, without Google, I pored over the medical literature to help me figure out what to do. And what I found was—confusion. The research was contradictory. Much of it was poorly designed, as research with human subjects often is. And even the best of it dealt with statistics and probabilities that were far from ideal: if there was a 50% chance that someone with clinical findings and test results that more or less (but never exactly) coincided with mine would get a 50% improvement from a certain surgery, what did this tell me? How much would I have to suffer to be willing to have a go at it with odds like that?
Although the decision was ultimately up to me, it was also clear that each of my doctors brought his/her own biases and preferences into the mix. Some seemed rather knife-happy; others were ultra conservative. Some favored a certain type of surgical intervention, others had a different procedure they preferred and with which they were more comfortable. Some required a particular series of tests as part of the diagnostic workup; others thought some of those tests to be unnecessary and dangerous. And on and on and on.
I learned from this and other medical encounters that except for a fairly limited number of conditions, medical science is not in a very advanced state in terms of offering a clear path for dealing with a certain problem. This is not due to some nefarious scheme on the part of doctors to keep easy cures from us, it’s just the nature of the beast. Nor did I encounter many doctors who seemed to be eager to perform surgery just for the sake of getting money; nearly everyone seemed to be earnestly trying to give me the best advice they could in solving a knotty problem.
Which brings me back to the topic of the day: how can we cut the fat that we know is in health care? The difficulties involved in making such decisions are profound, as well I know, but it’s not as though the Obama administration is the first to confront them. Patients, doctors, insurance companies, hospitals, and researchers have been wrestling mightily with them for decades, and the evidence is still conflicted and difficult to apply.
The difficulty lies not only in our lack of clear information to guide us. Some of the problem stems from the fact that we want an impossible combination: the very best health care possible with no person left out because of inability to pay, and a system that is affordable. Since the very best health care is only affordable if a person is either very rich or very healthy (or, preferably, both), there’s an inherent contradiction there.
Which brings us back to Obamacare, which ignores the contradiction by pretending that it does not exist and/or by pretending that we can cut through the Gordian knot by relying on research to tell us exactly which procedures are necessary and which are not—and to somehow do all of this without rationing health care or limiting patient freedom of choice in a way that the public will find onerous.
And any system that injects the federal government into the decision-making mix though a public health plan is almost by definition going to be costly and inefficient, whatever the administration promises. What’s more, such a system is likely to slowly but surely (or maybe even quickly and surely) crowd out the private alternatives.
Take a look at these current suggestions for health care cost-cutting (hat tip: Maggie’s Farm):
Under the [health care providers] groups’ proposals, certain types of care could see cutbacks, potentially sparking concerns among consumers. For example, the American Medical Association, which represents doctors, is proposing to “reduce unnecessary utilization” in areas including Caesarean sections, back-pain management, antibiotic prescriptions for sinusitis and diagnostic imaging tests…
These have been tried for years, and are all subject to the sort of problems I described when speaking of the history of my back problems. And everybody knows—or should know—how poorly the Canadian system, for example, meets the needs of its chronic pain patients, and how difficult it is to get an MRI there.
If you would like to emulate Canada, see what you think of this—not only is the wait long for MRIs, but the system is nearly impossible to bypass even if a patient wants to pay out of pocket:
After one month, you can’t wait any longer. You decide to dip into your savings to pay for a private MRI. To your dismay, every healthcare facility you call turns you away (except those in Quebec because of a 2005 Canadian Supreme Court decision), claiming that it’s against the law to sidestep the public health system to purchase certain procedures privately, like MRIs.
No wonder you constantly hear of not just rich but middle-income Canadians and high-profile politicians heading south to the States to skip the line, get tests like these done privately, and pay out of pocket.
Part of the reason the Canadian system can continue to function without a revolt (aside from the general affability of Canadians) is that the United States acts as a sort of safety valve for all save the poorest of its citizens. But what will the Canadians do when we’re all in the same leaky boat?
Ah, but Obama can move the sun and earth and stars and stop the rise of the oceans. So I’m certain that he and the wise Democrats now in control of Congress can find a way to do what no previous administration and no country on earth has ever managed to accomplish—to reconcile these contradictions and make the best health care on earth both affordable and available to us all.