Some Truth Behind the Rhetoric

Living in Washington, DC is weird. I should know - I used to live there. The food scene is great, and there are a lot of young people who bring energy and relentlessly baseless optimism to the place. But everything closes early. Public transit is built around the needs of commuters and tourists. Almost no one, other than the city's African-American population, actually is born, lives, and dies in the area. And then there's the infestation of politicians.

Inevitably, it starts to influence people's minds, like Steve Pearlstein, who actually writes the occasionally smart business column in the Washington Post. However like most DC/NYC public intellectual types, hanging out in the halls of power clouds his perceptions, and it annoys me. Behold this quote from a column of his attacking Republicans for being "political terrorists" in the health care debate:

While holding themselves out as paragons of fiscal rectitude, Republicans grandstand against just about every idea to reduce the amount of health care people consume or the prices paid to health-care providers -- the only two ways I can think of to credibly bring health spending under control.

When Democrats, for example, propose to fund research to give doctors, patients and health plans better information on what works and what doesn't, Republicans sense a sinister plot to have the government decide what treatments you will get. By the same wacko-logic, a proposal that Medicare pay for counseling on end-of-life care is transformed into a secret plan for mass euthanasia of the elderly.

Now by and large I agree with him that Republicans are being fear mongers in this debate but he's not being honest when he says that our only choice is to "reduce the amount of health care people consume." He assumes, since he lives in DC, that the government must be more heavily involved in health care. Instead we could also use proper pricing to make people understand health care costs. But once he assumes that government is the answer, what he's saying, inevitably and unavoidably, is that some people who are "over-consuming" care will be limited in their access to care. If he admitted this, he'd understand that the reason why the Republicans "wacko-logic" is working with people is that the public rightly understands there's no such thing as a free lunch. The Democrats are soft-peddling the impact of their proposed changes and the impact of those changes.

Using very vague phrases like "better information on what works and what doesn't" is dancing around the fundamental issue. Note that Pearlstein doesn't say "perfect information." People facing life threatening situations don't want to hear about probabilities and costs. They don't want to hear that if something PROBABLY WON'T WORK that they can't have it because it's too expensive. And it's not easy for a bunch of experts to decide what "works" and what doesn't.

Imagine a 10 year old child who's life can be saved by a procedure with a high probability of success and very high cost. Now imagine a 75 year old columnist for the Washington Post who needs an expensive operation that might only extend life for a couple of years. In our screwed up system it is more likely that the old fart columnist would get the operation because of Medicare. That's wrong in my view. A panel of "experts" are more likely to do the opposite, but even they might discover that the child would die in a few years and the 75 year old might live another 25 or 30 years and add productively to society. And no matter what anyone on the left says, they will have to limit access to certain procedures based on "better" information. Overall society will save some money, but individual choice will be limited.

Which brings me to today's column by Pearlstein on the breast cancer recommendations. Much like many folks in the MSM, he's sort of surprised by the hoopla. After reviewing what the panel did, he says:

All that, of course, is exactly what the task force did, based on numerous studies done in different countries using different methodologies. In the end, it found that while some lives might be saved each year, the benefits of annual screening of women in their 40s were outweighed by the costs -- and that's without even getting into the financial costs, which run to several billion dollars a year.

That's the most honest statement I've seen yet about this entire debate. As I've noted here on a number of occasions, you CANNOT change this system without altering the winners and losers. If the reforms as currently written go through, more people who currently do not have health insurance and decent, not awesome, coverage will get it. In addition, people with awesome coverage (AARP and old farts I'm looking at you) will see an erosion in quality and access. Costs will increase. You can't get something for nothing.

Now if, IF we were going to have an honest discussion of these issues I'd start here. But since honesty has never been part of politics, I'd settle for compromise. Why not expand Medicaid for the poor and down-trodden. Push for cost controls in Medicare, and create a health system where people actually saw the costs of their procedures? That would, in my humble view, limit "over-consumption" or at least place those costs on those consuming. It's called personal choice and responsibility combined with broad public charity. It wouldn't kill us to start here.