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Wednesday, 14 September 2011

Obama on Medicare - Good Clinical Ethics/Poor Partisan Politics

I was torn by Robert Pear's report in today's New York Times that Democrats are distressed about President Obama's proposal for a $300 - $500 billion reduction in Medicare and Medicaid spending over the next ten years.

I hate to see anything that will help mad dog Republicans. But clinical ethics support President Obama's stance.

Representative Emanuel Cleaver II, Democrat of Missouri and chairman of the Congressional Black Caucus, explained Democrat fears - offering such proposals “cancels out any bludgeoning that Democrats might give the Republicans over Medicare and Medicaid.”

"They [fill in the blank with your favorite opponent] will destroy Medicare" is a superb political bludgeon. It worked for Republicans in 2010 and for Democrats in 2011. For winning elections, stonewalling on Medicare cuts is the best policy.

But apart from the obvious need to constrain Medicare costs for the sake of a healthier federal budget, the right kind of cost constraints will be good for the health of Medicare beneficiaries!

Increasing the retirement age is exactly the wrong kind of "cut." It would transfer costs to others and harm all of those who became uninsured when they lost employer insurance before they became Medicare eligible. Increasing premiums, cost sharing, or both, especially for lower income beneficiaries, is almost as bad - it would lead to avoidance of needed treatment and worse health.

The sweet spot for Medicare cost containment is in overtreatment and defensive medicine. Anyone close to health care provision, whether as a clinician, administrator, or family member, knows just how common it is for beneficiaries to receive unneeded diagnostic, therapeutic, and even preventive, interventions. Apart from wasting beneficiary and taxpayer money, unneeded interventions cause all kinds of harm, through their own side effects or harms caused by other interventions done in follow up.

Economists say that malpractice reform can't be looked to for significant savings, but I don't think they understand just how toxic fear of litigation is for physicians. In addition to leading to defensive medicine practices like unneeded MRIs, concern about litigation synergizes with our cultural tilt towards the false belief that more is always better. It's time for Democrats to get on board with tort reform.

Twenty five years ago, my friends David Himmelstein and Steffie Woolhandler wrote about US administrative practices as "Cost without Benefit." I'm convinced that within the sphere of clinical care we have more than 5% of cost-without-benefit-and-often-with-harm. Reducing that segment of Medicare costs is the right thing to do - for beneficiaries as well as for the budget!

The fact that good clinical ethics could be bad politics is a symptom of pathology in our political process.


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