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On November 17, 2009, the US Preventative Services Task Force, a panel of experts working under the auspices of the US Department of Health and Human Services, issued a report that turned conventional wisdom on its head.
After the investment of decades exhorting women to get early mammograms and to perform routing self-examination as screening for breast cancer—and after racking up several years of improving survival rates for breast cancer—these experts recommended a retreat in the war against breast cancer. Against the advice of the American Cancer Society, and against the advice of most practicing physicians who work with breast cancer patients, the panel advised women to get mammograms starting at age 50 (instead of 40, as currently recommended), and to get them only every other year, rather than annually, for screening screening purposes once they turn 50. In addition, the panel “poo-pooed “ the usefulness of breast self-exams.
The panel of experts consists of doctors and nurses who primarily work in public health administration, and rarely engage in clinical practice with patients. Not one is a radiologist, oncologist, or surgeon who cares for cancer patients (like myself).
The resulting firestorm that the panel’s findings set off is by now well known. Secretary of HHS Kathleen Sibelius, to whom the panel is ultimately accountable, distanced herself from the panel’s findings and urged women to stay with the screening regimen currently in use. She assured the public that the panel’s findings are merely recommendations, and not enforceable. But don’t be fooled. Section 3201 of the health care reform bill that House Speaker Pelosi rammed through to passage in the dead of night two Saturdays ago explicitly states that the US Preventative Services Task Force shall determine what preventative services will and will not be covered by the mandated health insurance plans.
But this provided the public with a preview of what the not-too-distant future holds in store for us, as Congress is poised to have the federal government assume a greater role in paying for the cost of health care in the US.
The health care reform plans under consideration in the House and Senate have much in common. They both require, under penalty of law, that every person purchase health insurance.
They both create government “health insurance exchanges” which will provide the only legal avenue in which individuals may purchase the insurance. The federal government will determine what kind of insurance can be made available for sale in these exchanges—what must be covered, the maximum deductibles, the maximum co-pays that patients may have, etc. They will set requirements on what conditions must be covered. In effect, the federal government will turn the insurance companies into utility companies. The government, leaving only the administration of the insurance plans to the private companies will set the policies, terms, and rates.
Independent analyses by virtually every entity that studies health care policy have concluded that the new, government-mandated insurance will raise premiums significantly higher than they are today.
To help alleviate the added burden in paying for premiums, both the House and Senate plans create generous subsidies for those under 400% of the poverty level (over $80 thousand per year).
And both seek to create a taxpayer-supported, government-run and government-owned plan, the so-called “public option,” as an alternative for those who wish to avoid paying the premiums that the privately-managed insurance plans must charge in order to remain economically viable. The public option amounts to a form of Medicare for those under the age of 65. This is being proposed at a time when Medicare’s trustees report that Medicare will have a $37 trillion unfunded liability as of 2017.
All of this means more taxpayer money will be committed to the nation’s health care budget than ever before. Trillions of dollars will be added in liabilities to a federal budget that is already $1.4 trillion dollars in the red.
So cost containment will have to be of paramount importance.
That’s why both the House and Senate versions of health care reform establish commissions (in the case of the Senate, a 15 member commission appointed by the President and not accountable to Congress) which will set budget targets for each year, by determining what will and will not be covered by health insurance.
In the case of Medicare, the Senate bill requires the commission to make certain that by 2019, the rate of growth in Medicare expenditures is no greater than 1% more than the growth in GDP. The commission is mandated to go “after sources of increased growth,” meaning treatments considered too expensive or that may lead to increased spending.
Armed with data collected from the national electronic medical database—created by the economic stimulus bill passed in February 2009 (by 2014, every health provider of every type in the US must input every bit of information they have about every patient or pharmacy customer)—the Federal Council for Coordinating Comparative Effectiveness Research (also established in the stimulus bill) will publish their findings and recommendations regarding what is and is not cost-effective.
In the UK this is called the National Institute for Comparative Effectiveness (NICE). There, it sets rules as to what people, of what age, will be allowed hemodialysis, joint replacements, coronary bypass, etc.
In Washington State, a similar commission was set up in 2003 to control the state’s burgeoning Medicaid costs.
So far, it has banned knee arthroscopy for osteoarthritis, discography for chronic back pain, and implantable infusion pain pumps for pain not related to cancer. Under consideration are bans on joint replacements and MRIs of the abdomen, pelvis or breasts for cancer. It is also considering a ban on drug-impregnated coronary artery stents, in favor of cheaper bare metal stents (even if they have worse outcomes).
In Massachusetts, where a health plan that inspired the present Congress has been in operation since 2006, a budget crisis has resulted. To cope with that crisis, the state has created a legislative commission that has recommended moving the entire market to a single, Canadian-style payment system that would encourage doctors and hospitals to ration care.
The Legislature also plans to leverage its power under the individual mandate to require "evidence-based purchasing strategies," which is another way of saying government bureaucrats may soon be deciding who gets medical care and who does not.
When commissions make determinations as to the “comparative effectiveness” of particular treatments or preventative regimens, they are, of necessity, looking at things on the “macro” level.
They are viewing entire populations, and deciding what is the best way to allocate scarce dollars among an entire national (or state) population. Viewed in this holistic way, their findings might be quite reasonable. But they lead to conclusions that are generic, and rarely apply to individual patients, who have different biologies, response rates to treatments, and often multiple conditions.
And each individual has his/her own risk aversion threshold. A screening mammogram might seem like a waste of money to a “bean counter” trying to create a budget for 300 million Americans, but it might be a sound investment for a 40 year old woman with young children (such as the CEO of my hospital who had an early screening mammogram that picked up a cancer).
In a way the timing of the Preventative Services Task Force was fortuitous. It alerted the public to the inevitable Orwellian commissions that the health care reforms under consideration in Congress will engender.
If we are all forced to purchase government-designed, government-subsidized health insurance, either through an exchange or through a “public option,” we will all be subject to the edicts of a panel of bureaucrats.
Perhaps the Task Force’s announcement will spark a public uprising that stops this Congress from doing what it seems determined to do.
The term “death panel” has been derided as a histrionic exaggeration. But a woman condemned to a virulent form of breast cancer because she was denied a screening mammogram might not consider the phrase to be over-the-top.
Dr. Singer is a general surgeon in clinical practice in Phoenix, Arizona, and Treasurer of Arizonans for Health Care Freedom ( www.azhealthcarefreedom.com )
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