by Matt Kibbe
In other words, the more the government spends in a top-down system, the less care patients receive.
NOT SO NICE
IN THE U.K., THE RATIONING PROCESS IS QUITE TRANSPARENT. IT puts a remarkably specific monetary value on human life, expressed in pounds sterling. The Quality Adjusted Life Year, or QALY, is the amount of money that NHS experts have determined an additional year of a human life is worth, based on various factors, such as one’s current age, medical condition, and the likelihood of benefiting from the treatment. Generally, if a treatment costs more than £20,000 to £30,000 per additional QALY gained through the treatment (an arbitrary limit determined by budgetary constraints), then it is deemed “not cost effective,” and individuals and families who want those treatments are left to pay for them entirely out-of-pocket, sometimes by traveling abroad.7
The name of the agency that crunches the Quality Adjusted Life Years to determine if you are worth treating? The National Institute for Health and Clinical Excellence, NICE.
Just to prove how not-so-nice NICE is, the bureaucracy has rejected the use of the often life-extending drug Avastin (bevacizumab) for use in shrinking cancerous intestinal tumors, because “the cost . . . at about £21,000 per patient, does not justify its benefits.” Avastin is used in the U.S. and across Europe, but will now be effectively unavailable in the U.K. NICE’s decision, which came after a year of internal deliberation, will affect an estimated 6,500 NHS patients.8
Nice.
In Canada—which in the 1970s adopted a variant of the “single-payer” model (the rationing decisions are made in the provinces rather than in Ottawa)—the national median waiting time from the moment you see a doctor to the time you actually receive your treatment was, in 2010, a brisk 9.3 weeks. That’s the median. If you were a woman in need of gynecological help, your median wait was 15.5 weeks. Had a brain problem? Canadian neurosurgeons were able to see you in just 29.7 weeks. Orthopedic surgery? 35.6 weeks. Urological treatment? 13.5 weeks.9
Those are statistics. But the tragedy of government-run health care is best understood by looking into the faces of the suffering. Canadian newspapers are filled with horror stories of citizens suffering while standing in line. The following item from the Toronto Star December 2010 is just a typical example:
It’s no surprise to Thelma Lee that emergency room wait times are not meeting provincial targets.
Lee said her 41-year-old daughter, Marlene Stephens, died Saturday after waiting nearly 90 minutes at the William Osler Health Centre’s Etobicoke campus emergency room with breathing problems.
Lee feels her daughter was not seen fast enough by medical staff.
“They didn’t touch her,” said the grieving Lee. “She was crying out, ‘I can’t breathe, I can’t breathe.’ . . . Nobody attended to my daughter.”10
Somebody should be fired, you say. Heads should roll. How could this happen in socially progressive Canada, the land of free universal health care? Well, read on:
On Monday, Auditor General Jim McCarter released his annual report which found that despite putting an extra $200 million into shortening emergency room wait times over the last two years, “significant province-wide progress has not yet been made.”
Emergency room waits for people with serious conditions sometimes reached 12 hours or more, the report said. That is far greater than the province’s 8-hour wait time target, the report found.
And for emergency patients who need a hospital bed, they waited on average for about 10 hours but some waited 26 hours or more, according to the 2010 Annual Report. . . .
“This should not be happening in Canada,” Lee told the Star.11
This should not be happening anywhere. But it does happen, where the system is more important than the customer, where health care is a “right,” too important to be left to market forces.
Canadian Dr. David Gratzer learned the hard way about the gap between the legend of centralized health care and the reality. In fact, he was mugged by that reality, and became a convert to health care freedom.
My health-care prejudices crumbled not in the classroom but on the way to one. On a subzero Winnipeg morning in 1997, I cut across the hospital emergency room to shave a few minutes off my frigid commute. Swinging open the door, I stepped into a nightmare: the ER overflowed with elderly people on stretchers, waiting for admission. Some, it turned out, had waited five days. The air stank with sweat and urine. Right then, I began to reconsider everything that I thought I knew about Canadian health care. I soon discovered that the problems went well beyond overcrowded ERs. Patients had to wait for practically any diagnostic test or procedure, such as the man with persistent pain from a hernia operation whom we referred to a pain clinic—with a three-year wait list; or the woman needing a sleep study to diagnose what seemed like sleep apnea, who faced a two-year delay; or the woman with breast cancer who needed to wait four months for radiation therapy, when the standard of care was four weeks.12
As in Canada, Obamacare doesn’t contain explicit rationing. But it does establish the basic building blocks of a rationing infrastructure eerily similar to Britain’s. The law creates a new Patient Centered Outcomes Research Institute (PCORI) to determine the comparative cost effectiveness of medical treatments and therapies.13 Meanwhile, a new Independent Payment Advisory Board (IPAB), an unelected panel of fifteen health industry experts, will be using that cost-effectiveness data to impose hundreds of billions of dollars of Medicare “savings,” which can only be stopped by a majority vote in both Houses of Congress.14 IPAB will be one of the most powerful boards ever created. For now, its reach only extends to Medicare. But as the largest health care system in the country, Medicare’s coverage and payment policies—and price controls—have an enormous influence on private-sector health care delivery. And President Obama has already signaled a desire to extend IPAB’s reach to cover the private sector directly, through the bureaucratic apparatus established under Obamacare, if he can’t hit his budgetary targets otherwise. If these two new agencies (PCORI and IPAB) are allowed to go into operation in 2014 as planned, they will constitute an American version of NICE. They create the machinery of care denial.
But don’t call them death panels.
Anyone who doubts that Obamacare paves the way to bureaucratic rationing should consider the public statements of Dr. Donald Berwick, who served as the president’s Medicare chief until forced to step down last year after Congress declined to confirm his appointment. Dr. Berwick, who was knighted by Queen Elizabeth for his outspoken admiration for the NHS, lauds Britain’s rationing of medical care and even more loudly defends the practice as unavoidable in America.15 “The social budget is limited,” he argues. “We have a limited resource pool,” and “the decision is not whether or not we will ration care. The decision is whether we will ration with our eyes open.”16
Whose life is it, anyway? And what exactly is a social budget? The real decision, the only one that really matters in health care, is Who will decide? Who will decide how scarce resources are to be allocated: patients or bureaucrats?
ARE PATIENTS CUSTOMERS?
HEALTH CARE IS THE ONLY INDUSTRY THAT DESCRIBES ITS CUSTOMERS as “patients.” Think about that. We don’t think of the consumer of medical goods and services as a customer. We think of him, rather, as the passive recipient of care provided by somebody else. And that somebody else, we don’t call a “seller” but a “provider.” We even prefer to speak of medical goods and services by the more soothing term: care.
Patients. Providers. Care. Clearly, we view health care as different from other industries. And the sanctity of the doctor-patient relationship really is a key to personalized care. But viewing health care as different from other industries has opened the door for drastic centralization, which has led to many of the problems rampant in our system today: endemic medical inflation, widespread lack of coverage, limited access to vital new therapies, and people losing coverage when they change jobs.
These are all re
latively recent developments. Before the twentieth century, nobody ever thought of the doctor-patient relationship as something that should include a bureaucrat. Bureaucratic health care—by whatever name we call it, be it “national health insurance,” “socialized medicine,” “single payer,” “Medicare,” “Medicaid,” “managed competition,” the “Affordable Care Act,” or whatever—is a recent innovation, historically speaking. There was a time, not all that long ago, when government bureaucracies didn’t bother to take any notice of the doctor-patient relationship, let alone try to meddle with it.
But meddle they have. And do. And will. Until we stop them. And the first step to stopping them is acknowledging that the provision of health care is, in reality, a marketplace like any other.
The ancient code of the physician famously begins, “First, do no harm.” But the oath of the bureaucrat can be summed up as “First, obey the rules.” The doctor begins with his patient; the bureaucrat, with his orders. The physician’s oath reminds him that, in using his knowledge and skills, he is acting with a responsibility to an individual. By contrast, the bureaucrat is, by law, to enforce a “system” from the top down. The loftier the goals of that system—the broader its scope, the more ambitious its promises—the more sweeping must be the bureaucracy’s powers. And when that system is premised on an asserted universal “right” to health care, then the bureaucracy’s powers must grow beyond mere administration of “benefits”—it must place the bureaucrat more and more in the shoes of the physician himself.
For the doctor, when he and his patient are acting freely in a kind of medical marketplace, the patient is also a customer whose needs and wants must necessarily come first. For the public employee, acting within an elaborately constructed “system,” the patient must always come second, if he is thought of at all. The rules come first. The system is what matters: there is a social budget, after all.
What’s at stake in the health care debate is nothing less than whether we, as patients, will be free to choose our doctors and medical treatments or have them chosen for us—and potentially denied to us—by bureaucrats. Either we will choose, or some third party will choose for us. There is no middle ground. There is no room for a bureaucrat between you and your doctor.
HEALTH CARE AT THE TIPPING POINT
MOST OF THE PROBLEMS OF THE U.S. HEALTH CARE SYSTEM ARE symptoms of a single underlying disease: centralization from the top down.
Even before Obamacare, government’s share of the health care sector was large and growing. Health care expenditures currently represent about 17 percent, or one-sixth, of total national output. Nearly 40 percent of the health care sector (or about 10 percent of the whole economy) is controlled by government at the federal, state, or local level. Health care is growing as a share of the economy, which can be a good thing, if it means medicine is getting better. But government’s share of health care is also growing, which is a bad thing, because government involvement is always a drag on efficiency and innovation. With the enactment of the Patient Protection and Affordable Care Act, the distinction between public and private is effectively at an end. The federal government has effectively nationalized one-sixth of our economy.17
The relative inefficiency of the government, compared to the private sector, combined with government’s proneness to cause inflation and retard innovation, means the growth of government health care is inevitably driving costs up while driving quality down. And these destructive effects will only worsen if Obamacare is allowed to come fully online, on New Year’s Day 2014.
Remember when Nancy Pelosi said we needed to pass the bill to find out what was in it?18 Well, I have read it. Besides creating two massive new entitlement programs (Obamacare and CLASS, a Medicare-like entitlement to nursing-home care), the 2,801-page bill establishes 159 new bureaucracies. These remote and faceless entities include: 47 new agencies, boards, and commissions; 68 new grant programs; 29 new demonstration and pilot programs; 6 new regulatory systems and compliance standards; 4 new loan forgiveness and easy loan-repayment programs; and 3 reforms to existing Medicare reimbursement policies.19
The legislation includes such promising new entities as the Commission on Key National Indicators, the Private Purchasing Council for State Cooperatives, the Consumer Navigator Programs, the Exchange Grants Program to Establish Consumer Navigator Programs, the Independent Payment Advisory Board, the Consumer Advisory Council to the Independent Payment Advisory Board, the Program for the Use of Patient Safety Organizations to Reduce Hospital Readmission Rates, and the Pregnancy Assistance Fund.20 Regarding that last one, I will resist the urge to speculate as to what exactly our government has planned.
The secretary of health and human services has already begun to wield the 1,968 new powers delegated to her under the law.21 And if you’ve been concerned about the nation’s high unemployment rate since 2008, you’ll be happy to hear about the 16,500 new IRS agents22 they’ll be hiring to collect the law’s $569 billion in new taxes they’re levying on everything from upper-income folks (of course) to tanning beds.23 Another count, by the experts at the Congressional Research Service, declares the number of new bureaucracies created by Obamacare as essentially “unknowable.”24
Conservatively speaking, this alphabet soup of new government bureaucracies will cost $2.6 trillion over the first ten years of full operation.25 And that’s with optimistic assumptions. Recall that back in the 1960s, official government projections underestimated the initial ten-year cost of Medicare by 700 percent.
In ramming this unpopular monstrosity through Congress, on a strictly partisan basis, Harry Reid had to twist arms, bend rules, and buy votes with a series of astonishingly large earmarks. One can’t help but enjoy the colorful nicknames bestowed by the press on some of these legislative bribes, like the “Louisiana Purchase” (given for the vote of Louisiana’s Mary Landrieu, who actually took to the Senate floor to celebrate and defend her bribe), the “Cornhusker Kickback” (which bought the vote of Nebraska’s Ben Nelson), the “Gator-Aid” (given to Florida’s Bill Nelson, to help get the bill out of committee), and the “Conn-U” (the payoff dramatically held out for by Connecticut’s Hamlet-like Joe Lieberman).
The Democrats calculated that, once their unpopular bill had become law, public opposition would subside, as voters finally “found out what was in it.” But it hasn’t played out that way. One of the reasons is the hundreds of “waivers for favors” bestowed after the fact on the administration’s friends and supporters. True to Gammon’s Law, this massive new regulatory scheme has “customers” attempting to escape the bureaucratic “black hole” like rats fleeing a sinking ship. HHS documents show that the administration has been granting waivers from the law’s more onerous requirements hand over fist—especially to its friends. A total of 1,625 groups representing 3,914,356 individuals are now exempt from some of Obamacare’s more onerous mandates.26 Recipients include large corporations, health insurance companies, and even whole states. By far the biggest beneficiaries? Labor unions, representing 543,812 workers.27
Welcome to the government system, where who’s in and who’s out and what care you get and don’t get is based on your political “graft and pull” in the system. Lost in translation: patients, and their intentions and choices.
YOU WILL PAY
ONE OF THE MANY TRAGEDIES OF OBAMACARE IS THE SO-CALLED “INDIVIDUAL mandate” to buy a government-defined benefits package that you may not want, may not need, or cannot afford. No matter. You will buy it, or you will pay dearly. Polls show this mandate to be the single most unpopular aspect of the entire scheme: two-thirds of Americans oppose it, and 72 percent think it’s unconstitutional.28 But this will never stop its supporters from clinging to it, to the bitter end. By their own repeated admissions, the mandate is the law’s linchpin. Without it, their whole scheme unravels.
The mandate, in its essence, asserts a power on the part of the federal government to regulate you simply because you live and breathe. Think about the imp
lications of such government powers over your individual freedoms.
So where exactly does the Constitution grant Congress the authority to tell us to buy health insurance? The law’s defenders point to the power to regulate interstate commerce . . . or wait, is it the General Welfare Clause? . . . the taxing power? . . . well, um, it’s probably in the Fourteenth Amendment somewhere. Hmm. Okay, they’re not really sure by what authority they’ve mandated it, but they just know it’s constitutional. In February 2012, Congresswoman Kathy Hochul, Democrat from the 26th district of New York, committed a classic gaffe—let the truth slip out—when she admitted to an astonished group of her constituents: “Well, basically, we’re not looking to the Constitution on that aspect of it.”29
Arguably the most victimized constituency under Obamacare—and there are many potential victims—is the Millennial Generation, young people who showed up in droves to vote for Obama. They worked for hope and change, but what they got was the short end of a typical collusion between health insurance interests and the Obama administration that forces younger, healthier, poorer people to subsidize the health care consumption of older, sicker, wealthier folks. Young people, already saddled with record joblessness and unprecedented debt from student loans, will be forced into the system to prop up a financial house of cards. But hey, at least they’ll now get a free ride on their parents’ insurance policy until they’re twenty-six.
Know who deserves a waiver? All 310 million of us.
GOVERNMENT FAILURE, MARKET SUCCESS