Political perils of cost control complicate health care reform

Even if health reform passes, the problem of rising costs will not go away. And politicians cannot confront the fundamental issue that Americans can't have all the health care they want.

Even if meaningful health care reform becomes law this year at press time the outcome was still in question the problem of rising costs will not go away. Although the health reform bills intend to bend the cost curve, experts generally agree that much more will need to be done to lower costs. But effective cost control is particularly perilous for politicians.

Health spending is rising so rapidly that good care will soon be out of reach for most Americans, even as it drains the federal treasury, depresses wages and undermines the competitiveness of American businesses. Yet we don't have much time left to design policies to control costs, never mind find the political will needed to get them accepted.

Consider the following:

  • Health spending is expected to double to nearly $4.3 trillion by 2017;
  • If premiums grow in each state at the projected national rate of increase, then the average premium for family coverage would rise from $12,298 (the 2008 average) to $23,842 by 2020 a 94% increase, according to a Commonwealth Fund analysis;
  • If the cost trends of the past 10 years repeat, by 2019, employment-based spending on health care at large employers will be 166% higher than today on a per-employee basis, according to the Business Roundtable;
  • By 2017, Medicare Part A, which covers elderly inpatient visits, is expected to run out of money; and
  • Also by 2017, an average middle-income family who now makes $60,000 in gross wages (before taxes are deducted) will spend $4 out of every $10 they earn on health care alone, putting it out of reach for most, says respected Princeton economist Uwe Reinhardt.

Politicians understand that health care costs are unsustainable. But politics work against confronting the fundamental issue, which is that Americans can't get everything we want.

Controlling health care costs involves someone saying no. It may mean making people pay more when they insist on unnecessary care. It may involve punishing physicians who order more services and rewarding physicians who use fewer. It could even mean taking these choices away from physicians and patients by limiting the availability of expensive tests and elective procedures, the approach used in many other countries.

Yet politicians don't like to tell constituents they need to get by with less. It's easier to repeat the (arguable) mantra that “We have the best health care system in the world” than point out that the U.S. can no longer afford the health care it has.

Consensus on cost controls is hurt when politicians sling accusations of rationing. As Rep. Earl Blumenauer (D-Ore.) recounted in a November 15 op-ed in the New York Times, his sensible, modest proposal to reimburse physicians for discussing advance directives with their patients became fodder for critics who willfully distorted it as creating “death panels” to help government pull the plug on Grandma. Although respected independent fact-checking organizations immediately disproved this charge, it still became a staple of an organized political effort to discredit the House's health reform bill.

Similar charges were made against proposals to fund independent research on the comparative effectiveness of different treatments, or to require coverage of evidence-based services. Even the idea of paying physicians to organize care through patient-centered medical homes long championed by ACP was deceptively criticized as “this decade's version of HMO restrictions on care.”

It shouldn't be surprising that the health reform bills didn't propose more cost controls, but that they went as far as they did, despite the attacks and falsehoods. John Iglehart writes in the New England Journal of Medicine that “the bills contain no shortage of ideas for reforming the delivery system, enhancing the quality of care, and slowing spending. Pretty much every proposed innovation found in the health policy literature these days is encapsulated in the measures.”

One lesson from the health reform debate is that we shouldn't rely on politicians to make the right choices. Instead, might it not be better for the medical profession to lead the discussion on controlling costs?

Last fall, ACP released a position paper that analyzed the reasons for rising health care spending and proposed solutions, including assessing benefits and costs of new technologies before widespread adoption; incorporating comparative research into value-based benefits; increasing price transparency; involving patients in shared decision making; encouraging patient engagement in advance planning; designing new payment models to align incentives with value; and studying and recommending policy interventions to reduce regional variations in quality and cost of care.

Many of ACP's proposals are controversial, because they would limit how much health care any one person can use. They will create a difficult debate within the medical profession itself, because they would make physicians more accountable for delivering care more efficiently and effectively. Money would be redistributed, creating new categories of winners and losers. The best-compensated physician might be the one who gets the best outcomes while using the least resources, not the one who does the most procedures. But Mick Jagger had it right: “You can't always get what you want, but if you try sometimes, you just might find you get what you need.” Patients are likely to have far more trust in their physicians telling them what they need than in the politicians.