If Allowed, Special Interests Will Halt Health Care Reform

If you want to understand the contours of the coming debate over the broken health care system, you need look no further than Friday's Washington Post.

If you want to understand the contours of the coming debate over the broken health care system, you need look no further than Friday's Washington Post. Three very different stories illustrate how difficult it will be to find consensus and how easy it will be for a wide variety of special interests to prevent it. The sad truth is that many of those interests -- different players in the industry, nonprofit causes and ideological zealots and coalitions -- appear perfectly willing to try to obstruct change if their particular oxes are gored.

The most illuminating piece was a description by business columnist Steve Pearlstein of how conservative critics orchestrated an attack on a provision in the stimulus bill  that spends $1.1 billion for research into which treatements yield the best results for particular diseases. It was criticized as a first step toward centralized, government-controlled health care by many of the usual suspects on the right who delight in trying to find a liberal conspiracy behind every policy they dislike. Leading that charge was Rush Limbaugh, who tried to turn a respected research process into a sinister plot to deny the elderly expensive medical treatments and create a "duty to die" in the name of saving money.

Pearlstein charges that the campaign "was a work of political arson by the country's drugmakers and medical device makers, which have the most to lose if there is solid research showing that some of their most expensive and high-margin products aren't really better than the low-priced spread."

Of course any policy and effort intended to control health care costs could be carried out badly, and advocacy groups for vulnerable groups and patients should and will push for safeguards. But comparative effectiveness research is widely regarded by health policy experts of all stripes as a crucial part of any effort to make our health care system more efficient and affordable. Pearlstein points out that such research has been carried out for years and that the stimulus money -- which triples current funding -- is intended to  give a big and important boost to a serious tool to contain the health care costs.

The second story looks at how Wal-Mart, held up not long ago as an example of corporate irresponsibility for failing to provide adequate insurance, has become a leading innovator of policies and efforts to provide at least bare-bones but effective coverage to its low-income employees. Much of what the company has done could be important tools in a broader, national policy. But there are two key points in the story -- Wal-Mart relies heavily on government programs and other employers to stretch its program, and the company and its admirers both point out that what Wal-Mart is doing is patchwork and temporary. Only a coherent national policy can truly tame the health care system.

The third is about an alarming scandal. A research paper that had been given a government stamp of approval as independent and rigorous reassured residents of Washington that lead in the water system had not harmed their health. But unbeknown to the agency that published the paper, the researcher had been paid by the city's water authority under a contract that gave the agency final approval of the paper. There are now serious concerns that lead in the water has, indeed, caused harm. Given the promise of such tools as comparative effectiveness and potential medical breakthroughs in treatments, drugs and prevention, there is arguably no more important aspect of health care than a system of research and investigation that is based on hard scientific evidence and free from influence and corruption. This story is just the latest that points out how vulnerable our research structure is.

Any casual but discerning observer of the health care debate will notice that it is largely made up of ideological sloganeering and fear mongering: only a market-based system will hold down costs without taking choice and quality care away from Americans, for instance; only a single-payer system can keep evil insurance companies from short-changing patients and profiting from them is another common refrain. Another chief feature is that real reform means devising and implementing the very best possible system available -- and supporters of various approaches point to this country or that country as fine examples to mimic.

But in a brilliant article in The New Yorker, Atul Gawande points out that the most envied health care systems in the world, which all offer universal and affordable care but are very different in how they are constructed and executed, and America's own-employer-based system did not grow from grand design. They were expansions and improvements of existing systems that grew out of very specific circumstances unique to that nation's history, circumstances and politics.

Gawande's overarching point is that taking a brand new and alien structure, no matter how well intended and designed, and using it to replace an existing system will almost certainly be disastrous. Instead, he argues, policymakers need to stop looking at foreign systems and look instead to existing and familiar programs and structures that can be knitted together. That means expanding and reinforcing both the current employee-based system, perhaps with government subsidies for some employers and/or employees, and existing government programs while implementing proven reforms that can hold down costs. But to get there will mean identifying the various interest groups and constituencies and listening to their arguments and concerns, but also preventing them from shanghaiing the process. So, when you hear that your freedoms will be impinged, that your grandmother  won't get that cancer treatment, that profits will take precedence over care -- in short, anything that sounds calculated to make you angry or afraid instead of detailed and based on logic -- take a close look at who stands to lose what.

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