Monday, March 3, 2008

Lily-Livered Approaches to Health Care Cost Containment

In a recent JAMA article on the trade-off between cost and coverage, the always prescient Zeke Emanuel (my candidate for CMS director in the next administration) concludes "It's the Health Care Costs, Stupid." Here's the gist of Emanuel's argument:

"Without controlling health care costs, any attempt at universal coverage will be transient. Sustainable expansion of coverage to all Americans requires credible changes in the rate of health care inflation...In the strange calculus that is American politics, the more politically salient issue of costs may provide a better way to achieve the comprehensive reforms necessary to cover the uninsured than the hitherto futile direct moral appeal."

Unfortunately, the presidential campaign to date suggests that U.S. political discourse on health care costs continues to be lily-livered. The predominant approaches being proposed by both parties are wish fulfillment, magic, and blind faith.

Articles today and yesterday in the New York Times explain why both parties prefer the fairy dust approach to cost containment:

The toxic politics of appearing to support any rationing of care has kept candidates in both parties from seriously confronting the overuse and misuse of health care.”

the need for cutbacks is not a popular theme for political candidates wooing voters who want more care at a lower cost.”

John McCain promises that market forces, which have brought us unceasing cost increases, will reverse the cost trend if he is elected. (If you cling to the hope that markets will save us, read Robert Kuttner on "Market-Based Failure - A Second Opinion on U.S. Health Care Costs" in last month's New England Journal.)

Barack Obama and Hillary Clinton suggest that investing in prevention, electronic medical records, and disease management for chronic illness, will do the job. But as important and desirable as these actions are, they won't rein in the cost trend either.

We can't wait for political leaders to show us the way out of the cost morass. In the 23 years since John Kitzhaber was elected president of the Oregon Senate, no politicians have stepped forward to take the baton of educative leadership about access, cost, and rationing, from him. We need to create the conditions that will allow effective political leadership to emerge. This involves two key components:

1. More and better information on comparative clinical and cost effectiveness. We can't make progress on costs without persuasive information about how to achieve desired outcomes in less costly ways.

2. A political strategy for using this information. This is not a matter of developing ever more complex financing proposals, but rather, finding ways to make open discussion of cost containment and rationing less "toxic." Conservatives have shown how to do this with the "death tax" campaign.

Some years ago, as part of a panel on rationing, a member of the audience challenged me by asking "Are you going to market your health plan by saying 'we ration care better than anyone else'?" For a moment I was nonplussed, but then I channeled Karl Rove and responded - "I would say 'we produce more health for every penny you invest than anyone else.'"

If a political clod like me, who couldn't even get elected to high school student council, could develop a communication strategy for detoxifying talk about health care costs and rationing, the political pros could show us the way if they put their minds to it.

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