I try so hard not to focus on politics that sometimes I convince myself that deep down inside we are more alike than different. While that may be true for most things, once in a while I see something that forces me to realize that there are some philosophical divisions not easily overcome. For instance when I read the following from Paul Krugman today, I agreed wholeheartedly:
The main thing, though, is the strengthened role of and target for the Independent Payment Advisory Board. This can sound like hocus-pocus — but it’s not.
As I understand it, it would force the board to come up with ways to put Medicare on what amounts to a budget — growing no faster than GDP + 0.5 — and would force Congress to specifically overrule those proposed savings. That’s what cost-control looks like! You have people who actually know about health care and health costs setting priorities for spending, within a budget; in effect, you have an institutional setup which forces Medicare to find ways to say no.
In fact, I think this is my favorite part of the proposal. I spend a lot of time thinking about health policy, cost-effectiveness, and decision analysis. And I’ve said over and over that I favor a strong IPAB. Moreover:
[I] think we can have a panel of experts (which should include physicians) try and determine which care isn’t worth the money and stop spending as much public money on that. This will mean that if individuals want to get that care anyway, they have to pay for it themselves.
Knowing what works and what doesn’t is not easy; it’s complicated. Since we’re spending public money, I think it’s reasonable to say we’re not going to pay as much for things that don’t work as well. This is also part of value based insurance. I’m nodding even as I write this. Then I read this from Andrew Sullivan:
Even Krugman is happy. Because the Obama plan includes much greater power for top-down rationing dictated by “people who actually know about health care and health costs”. Gulp.
The “Gulp” made me pause. Readers of this blog know of my respect for Andrew Sullivan, so the fact that this made him nervous made me uneasy. It forced me to face the fact that there are many, many people out there who disagree with me, who think this is a bad idea.
I’m not changing my mind. I still think this is the best way to go. But it wil be important to make sure people understand that the IPAB and such will have public oversight and can be over-ruled. This also doesn’t stop people from getting care they want. It stops you and me from having to pay for that care when experts think it doesn’t work. If they still want it, they’re free to pay for it. Moreover, this happens already today. If you have private insurance, believe me, someone is deciding what your insurance will and will not pay for. It’s just not public, and I think that’s a bad thing.
It comes down to this, again and again. I think that experts are better positioned to make many of these determinations; others think that individuals are. This is not a little difference, it’s actually pretty big. But I’ll make the following concession: if you show me high quality research that proves me wrong, I’ll change my mind. Will those who disagree with me say the same?