Telling the Whole Truth

by Laurie Gelb, June 17, 2009

Watching the back-and-forth regarding “health care reform” calls to mind many untold truths – that it may not be too late to tell.

AARP’s monthly magazine has an “8 Myths About Health Care Reform” feature in the current issue that should not go unchallenged by any patient, let alone health professional. This “myth list” in fact recapitulates several red herrings propagated these days by many legislators, media outlets and influencers.

So, whatever your personal or professional position, here are a few talking points that you might consider attempting to insert into the debate before the dotted line is signed.

AARP’s “myth”	The reality
Those with insurance won’t benefit	AARP argues that new legislation will provide a safety net for those destined to lose their coverage in the future. “Just because you have health insurance today doesn’t mean you’ll have it tomorrow,” the author warns. Well, yes, that’s true, because many employers, associations and trade groups, many of whom cover people on the margins, are going to use a public plan option as an excuse to drop or limit access to their own plans. Thus, this is a self-canceling argument that skirts the stated objective of universal coverage (not to mention the somewhat paltry incremental 16M Americans gaining coverage estimated by the CBO this week).
Boomers will bankrupt Medicare	AARP points to costly technology (“think MRIs and CT scans”) and over-treatment as primary cost drivers of the current trend. Unaddressed is the difference between a scan that enables an early diagnosis and an improved prognosis, vs. a study that is not indicated, or effective vs. ineffective treatment. That private payors have been more active than Uncle Sam in identifying and addressing inappropriate care is never stated. However, it would also be helpful for payors to acknowledge that they have often ignored myriad opportunities to improve the aggregate efficacy of self care, and commit to greater action in the future (such as the decision support programs discussed in other posts).
Reform will cost us more	AARP makes the analogy between health reform and the upfront cost of an Energy Star appliance, reassuring its readers that by 2020, reform “could save us approximately $3 trillion.” Unstated is just how this might occur, though indeed you could wake up tomorrow as a British monarch. But we need to discuss the concept of annual budgets, something that most Americans understand, and the fact that Energy Star savings are quantifiable in a way that vague promises/threats about HIT, CER and (more) de facto rationing are not. Then we can begin talking about low-hanging fruit – treatments of unquestioned efficacy for the vast majority of a given patient population, to which access and adherence are suboptimal. At the same time,, fully involving privacy advocates and community clinicians, we can talk about standardizing the EHR and getting it to the point of care in a way that actually saves everyone time – and saves lives.
My access to quality care will decline	“Just because you have access to lots of doctors who prescribe lots of treatments doesn’t mean you’re getting good care,” counsels AARP. This sly truism in no way addresses the issue at hand, which is the extent to which public sector plans already inhibit access to care, if only because physicians withdraw from their networks every month. The time that docs and their staffs spend trying to eke (substandard) reimbursement from public plans is somehow omitted from this answer (and the entire AARP policy agenda). And, this week, MedPAC raised the spectre of denying coverage for “new drugs” unless they are “proven” superior to “old drugs” (not clear if safety or tolerability or convenience of dosing will count—it rarely does in the health care hells the politicians are claiming not to emulate), not to mention linking “value” of therapy to reimbursement – and AARP can continue pretending that the reform movement is “hands off” clinical and personal choice? Take a trip across the border or the ocean and see. [I’ve been in UK hospitals.] Again, AARP is only disingenuous to avoid discussion of what a clinical decision is, vs. what a political funding mechanism is.
I won’t be able to visit my favorite doc	Once again, the fact that many clinicians and facilities deny, limit or delay encounters with Medicare and Medicaid patients is nowhere stated. Instead, there’s the classic red herring reassuring readers that “clinical effectiveness research” is a good thing. Indeed, but how does that relate to physician access? It’s as if AARP shuffled the cards with the questions and threw them on top of a few “politically correct” answers.
ERs provide the uninsured with good care	AARP correctly points out an ER can’t be a medical home, and that the insured pay for part of the ER visits that result from uninsurance. But this is a straw man myth—no one is seriously suggesting that ERs substitute for insurance. The real question is, how do you get all these chronically ill people in need of monitoring access to primary care, when PCPs are already in short supply and becoming more scarce as you read this? How do you support better health decision-making across the board? How do you help a clinician at 2 am make a quick, accurate connection between the patient presenting to him and the same person who presented 500 miles away a month ago?
We can’t afford to tackle this now	AARP notes that people are delaying care and not filling rx, suggesting that reform is urgent. Indeed, no one questions that costs are soaring, nor that the current unfree unmarket is more like a bazaar. However, creating a sense of urgency doesn’t serve reformers’ objectives when basic questions like financing of the plan, contribution to the growing deficit and how clinicians and patients will be served are overlooked in the name of that urgency.
We’ll end up with socialized medicine	Quoting a RWJ researcher, AARP concludes its feature with the assurance that “we will come up with a uniquely American solution…a mixed public and private solution.” Well, most “single payor” countries count as a “mixed” solution, too, if you consider that many citizens in such countries, where possible, purchase additional private coverage because the public plans are so inadequate. As reassurance, this isn’t exactly warm and fuzzy, especially given the shortcomings of both our private and public plans. Mix them together, and you get the equivalent of goulash over jello. Moreover, AARP’s soothing words to the contrary, the signals out of Washington speak to a new willingness to consider a wide array of new controls over individual actions, from “Any Unwilling Provider” mandates to limits on therapy. “Socialized” is a buzzword, but health freedom is not. If the managed care sector doesn’t speak out – honestly and completely – about what’s good and bad about the current system, and promote proposals that address the real issue – the right person receiving the right treatment at the right time for the right duration – we may all be a good deal worse off – and poorer – a year from now.