Does anybody still read The New York Times Magazine? If not, everyone missed a recent interview with President Obama, in which he expounds, without a TelePrompTer, on his views on health care. In general, the interview reveals a good understanding of some of the challenges facing our system, such as high costs, especially during the end-of-life period. But it also hints at some unrealistic solutions, such as "comparative-effectiveness research" to drive down costs, an independent board to make health-care decisions, and some kind of non-democratic decision-making process that doesn't go through what he calls the "normal channels."
The president gets the interview off to a good start, encouraging consumer participation in the decision-making process. Consumer participation is part of what's known as "value-driven health care," an effort to use technology and transparency to let consumers make decisions based on both cost and quality of care. Obama even mentions an effort to correct "the asymmetry of information between patient and provider." This would let covered consumers make smart decisions that contemplate cost.
The problem is that while the Bush administration had a clear and serious belief in all four elements of value-driven health care — information about cost, information about quality, technologies to make that information transparent, and incentives to encourage consumers to use said information — it's not at all clear that Obama does. There's some doubt whether Obama even means the same thing that Bush did when he mentions consumer involvement.
Obama also mentions Medicare and Medicaid and our "obligation to get those costs under control." He is right about the problem of cost, but it was not clear what he could do to achieve this. While the White House is indeed looking for cost-cutting opportunities within Medicare, such ideas usually end up on Congress's cutting-room floor.
One broader cost-cutting measure he mentions is comparative-effectiveness research, a $1.1 billion effort via the stimulus package to compare different therapies and try to get to official judgments about which ones work better. His vision for comparative effectiveness is one of objective studies through which you will learn that "the blue pill, which costs half as much as the red pill, is just as effective, and you might want to go ahead and get the blue one." Once consumers have access to these studies, he believes, "if a provider is pushing the red one on you, then you should at least ask some important questions."
The problem with his vision of comparative effectiveness is two-fold. First, per the stimulus legislation, it is supposed to be a measure of effectiveness, not a cost-comparison tool. Second, and more important, this binary view of effectiveness (one therapy is more effective than the other) is not compatible with the emerging notion of personalized medicine, which takes individuals' genomic structures into account. Personalized medicine may teach us that while therapy A works better in the aggregate, therapy B might be better for some individuals based on their unique DNA. We have made great strides in bringing about personalized medicine in recent years, particularly through the unlocking of the human genome, but the technological challenges may pale before the policy obstacles that cost-cutters could place in personalized medicine's path.
A cost-cutting measure that he does not mention in the interview, but that began getting media attention yesterday, is the new health-industry-developed plan to reduce spending growth. It is an open question how "voluntary" these reforms from terrified industry reps really are, and how enforceable they will be in the future.
Another subject the president discusses with the Times is the problem of end-of-life care. He tells the story of his grandmother, who got an expensive hip replacement, then died two weeks later. President Obama says he "would have paid for that hip replacement just because she's my grandmother." At the same time, however, he notes that "whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else's aging grandparents or parents, a hip replacement when they're terminally ill is a sustainable model, is a very difficult question." Furthermore, he recognizes that Americans don't want to hear that we will not provide expensive late-stage care, a la England. As the president puts it, "If somebody told me that my grandmother couldn't have a hip replacement, and she had to lie there in misery in the waning days of her life — that would be pretty upsetting."
His answer to this question, however, is also somewhat upsetting — and not just because he calls denying care to the terminally ill "very difficult" and "upsetting," but never "something we won't do." He says that "there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place." And not only will this be difficult, he claims, but he has trouble imagining "the country making those decisions just through the normal political channels. And that's part of why you have to have some independent group that can give you guidance." It is unclear what this group will look like, but the notion of some empyrean body, developed outside the normal political channels, making health-care decisions for the country, is a notion that makes me very, very nervous.