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  • BIOETHICS FORUM ESSAY

The Blame Game: How to Evade the Cost Problem

The Congressional Budget Office recently issued a report laying out in stark detail the seriousness of escalating health care costs. Earlier reports by the Commonwealth Fund and the Kaiser Family Foundation and sundry analyses by many health care economists also stressed the unsustainability of rising costs, and public opinion surveys show that controlling costs is now taken to be as important as achieving universal health care.

But earlier this year, President Bush got a taste of what taking costs seriously leads to. In the 2008 federal budget request, he proposed cutting a number of government health programs – reducing spending on Medicare and Medicaid by $31 billion over five years, for example. He was assaulted when he first proposed these ideas, and he is under further attack now that Congress is considering them. The language of the criticism has ranged from “unreasonable” and “unrealistic” to “disastrous.”

I do not like Bush’s policies, and there are far better places to aim cost-cutting measures than those he has chosen. Even so, he has done what no Democrat has dared do: take on a nasty problem directly and in some detail. Responding to the president’s budget request, Senator Edward Kennedy said that Congress would, once again, give federal agencies more money than Mr. Bush asked for. So much for cost control.

I have no doubt that if some prominent Democrat proposed such a wide range of cuts, they would be equally excoriated, even if they were wiser than Bush’s. Serious efforts to control costs cannot fail to be distasteful. Universal health care is popular, by contrast, even if there are huge political differences on how it might best be achieved. It would mean giving millions of people what they need and what the rest of us already have. The control of costs would mean taking away from people what they now have and would hate to give up.

Kaiser and the CBO focus on technology as the main driver of rising costs. Working to cut that rise is likely to generate an even more hostile response than, say, reducing Medicare payments. Patients love and expect technology, doctors are paid to use it, and the medical industry makes billions of dollars selling it. From its inception, Congress has forbidden Medicare from considering costs in its coverage decisions. “Reasonable and necessary” is the only acceptable standard. Three federal agencies created by Congress over recent decades to assess technology were eventually killed or neutered under pressure from industry and physician groups.

The stumbling block in efforts to control health care costs, and particularly technology costs, is that our spending habits are deeply embedded in American culture. We are more health-obsessed than other developed countries, more driven toward technological innovation, more tolerant of commerce in medicine, more unwilling to set limits, and more attracted to consumer choice and provider competition as a way of managing costs.

Political leadership of a rare kind is needed. It will have to be countercultural, aiming to change some well-entrenched ways of life. It will have to be candid in telling people what we can no longer afford. It will have to find the will and the courage to resist the clout of industry lobbies. It will have to explain that less health care can be better for one’s health than more. It will have to say that nothing short of government regulation has shown itself able to control costs.

What can congressional Democrats do? Here are some possible steps: They can allow Medicare to consider cost. They can push for the creation of an office in the executive branch to identify and prioritize promising places to cut costs. They can work to change the ratio of primary care to specialist physicians, who are likelier to use high-technology medicine. They can take up price controls on pharmaceuticals and insurance premiums. Any step of that kind would be resisted. But failure to control costs will gradually gut both federal and private coverage. In fact, as the CBO report says, “Rising health care costs constitute the principal challenge of fiscal policy – no other single factor will exert more influence over the long-term balance of the federal budget.”

Published on: September 5, 2008
Published in: Health Care Reform & Policy

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