When Mitt Romney signed the Massachusetts health care plan into law, he bragged that it would provide universal health care coverage. In fact, he still says that on the campaign trail. After all, the plan does mandate that everyone in the state buy health insurance. The state has done pretty well at the welfare aspects of the bill, signing up some 150,000 people for subsidized insurance (families of four earning as much as $62,000 are eligible for subsidies). But the latest reports from Massachusetts indicate that of 170,000 people who are uninsured but have incomes too high for subsidies, only 17,500 have complied with the mandate so far. Someone should have pointed out that the Massachusetts mandate is probably unenforceable and almost certainly not going to achieve universal coverage. Oh, that’s right, we did.
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An Apology Is in Order
Yesterday, I posted to this blog regarding a paper by Michelle Bucci and Bill Beach of the Heritage Foundation. My post consisted almost entirely of one sentence from that paper; I offered no context.
Taken by itself, that lone sentence could be interpreted to mean that the authors support an income tax increase. I never for a moment considered that to be the authors’ position; the sentence was interesting to me for that ambiguity, not because I thought the authors support such a thing.
I have since been informed that my post read like an accusation, rather than something playful. A cheap shot, really. That was not my intention, and I apologize to Bucci, Beach, and their colleagues at Heritage.
I sometimes disagree with Heritage scholars, but it is important to me to keep those disagreements friendly and respectful. Here it seems I failed, and it wasn’t even over a disagreement. Sorry, guys. Yeeeouch, indeed.
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The Food and Drug Administration’s Deadly Policies
A devastating column in the Wall Street Journal calculates the death toll caused in part by the bureaucrats at the FDA. The paper-pushers refuse to let critically ill patients have access to experimental new drugs — even when those drugs already have cleared some clinical tests. In a free and just society, individuals would have the right to make those decisions:
The Alliance began pushing for access to investigational drugs for terminal patients after its founding in mid-2001 upon the death of Abigail Burroughs, who was denied an investigational drug (Erbitux) that an early trial showed might have helped her. She and her doctor were right, but she never got the drug. Over the past five years, the Alliance has pushed for access to 12 exceptionally promising investigational cancer drugs which have subsequently been approved by the FDA and now represent standard care. At the time we began our advocacy, each of the drugs had cleared at least preliminary Phase 1 testing, and in some cases more-advanced Phase 2 or Phase 3 trials. In other words, they obviously worked for some patients. …
In sum, these 12 drugs — had they been available to people denied entry to clinical trials — might have helped more than one million mothers, fathers, sons and daughters live longer, better lives. We have actually underestimated the number of “life-years” lost at more than 520,000, because we have not included other safe and effective uses of these drugs that the FDA has yet to approve. …
The American Cancer Society reports that some 550,000 cancer patients die annually, making the number of cancer deaths from 1997 to 2005 about 4.8 million. Over that same period, the FDA reports granting individual access to an investigational drug to not more than 650 people per year for all diseases and drugs — a pathetic, even cruel, pittance. A few thousand more patients managed to gain access by enrolling in relatively small clinical trials or exceedingly rare expanded access programs. The other 4.7 plus million cancer patients, not to mention millions more with other diseases, were abandoned to die, denied access to progress by their own FDA when they needed it most.
Grover Norquist & Co. Join the Anti-Universal Coverage Club
Here’s an excerpt from the Americans for Tax Reform blog:
Many debates in health care over the last decade (or five) have focused on the best way to universally insure all Americans.
The Left believes in a single-payer health care system where all Americans are covered by a single government health care plan.
The Center-Left believes in some combination of socialized medicine and heavily government-subsidized private sector health care.
The broad Center-Right coalition believes in individual choice and control, in particular via use of health savings accounts (HSAs).
But maybe we’re getting the question wrong.
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P4P: I Disagree with Arnold Kling and Dr. Bob
Arnold Kling agrees with Dr. Bob regarding existing efforts to pay physicians for quality — known as pay-for-performance, or P4P — rather than for the volume and intensity of the services they deliver. Dr. Bob argues:
- “High quality — while not invariably more expensive — is often so.”
- “[B]y and large,” the guidelines that physicians are supposed to follow “don’t exist — except in a few relatively straightforward areas of medicine.”
I agree with those statements, but I disagree with their conclusions.
Though the first statement is true, it is also true that a lot of the expensive stuff that doctors deliver is not high quality. For 30 years, researchers at Dartmouth Medical School have found it very easy to demonstrate that some doctors do a lot more expensive stuff than other doctors do (e.g., specialist consultations, hospital stays, etc.). But they have found it very, very hard to find any evidence that that extra stuff makes patients any healthier or happier. Thus, a lot of the expensive stuff that doctors do isn’t high-quality care.
Though the second statement is true, it is also true that where evidence-based guidelines do exist, patients still don’t get the “high-quality” care that the guidelines recommend. According to Elizabeth McGlynn and her colleagues, patients receive such recommended care only about 55 percent of the time. (I put “high-quality” in quotes because not every patient should receive what the experts recommend. But it would be a stretch to say that 45 percent of patients are outliers.) Even when evidence-based guidelines exist, doctors don’t follow them.
Quality suffers both because physicians don’t do enough of what they should, and do too much of what they shouldn’t.
Physicians generally support P4P incentives that pay them more to do more of the former. But they really hate P4P incentives that penalize them for doing too much of the latter. (The American Medical Association supports only two types of P4P incentives: those that increase the incomes of some physicians, and those that increase the incomes of all physicians.)
I think third-party P4P, where insurers reward providers for high-quality care, is a fine idea – provided the patient gets to choose her insurer. For a good overview of the quality problems in the U.S. health care sector, the difficulties in implementing third-party P4P, and why the federal government should stay out of the P4P business, read my law journal article.
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A Snub for the Dying
On Tuesday, the U.S. Court of Appeals for the D.C. Circuit ruled 8–2 that terminally ill patients who have exhausted all available treatments have no constitutionally protected right to access experimental treatments not yet approved by the federal Food and Drug Administration. A panel of the D.C. Circuit previously had ruled 2–1 in favor of the terminally ill patients who brought the case, Abigail Alliance for Better Access to Developmental Drugs v. Eschenbach.
The Abigail Alliance is named for Abigail Burroughs, who died of head and neck cancer in 2001 after failed attempts to access Erbitux (cetuximab) through the FDA’s existing channels. (In 2006, the FDA approved Erbitux for treatment of head and neck cancer.) The Abigail Alliance now represents similarly situated, terminally ill patients who only want one last shot at life. Eschenbach is commissioner of the FDA.
In an op-ed [$] in today’s Wall Street Journal, my colleague Roger Pilon discusses the tortured legal reasoning that led to the perverse conclusion that terminally ill patients do not have a fundamental right to save their own lives.
The scientific and economic argument supporting the FDA’s case is that we would get far less information about drug safety and efficacy if terminally ill patients could access unapproved drugs, because there would then be no incentive for patients to participate in the clinical trials that generate such information. There are a number of problems with this argument, the greatest being that it reduces Abigail Burroughs to a cog in some bureaucrat’s grand machine.
On September 25 from noon to 2pm, the Cato Institute will host a forum on Abigail Alliance for Better Access to Developmental Drugs v. Eschenbach. Speakers will include Scott Ballenger, lead counsel for the Abigail Alliance; Ezekiel Emanuel, chair of the Department of Bioethics at the National Institutes of Health; and yours truly. Keep watching Cato@Liberty or the Cato website for further details.
This week’s ruling brought to mind a quote from Mark Twain that appeared in the New York Times on February 28, 1901, and that Mike Tanner and I included in our book Healthy Competition:
The State stands a Gibraltar between me and anybody who insists upon prescribing for my soul what I don’t want to take.… Why shouldn’t I have equal liberty with regard to my body, which is of so much less concern? … Now what I contend is that my body is my own, at least I have always so regarded it. If I do harm through my experimenting with it, it is I who suffer, not the State.
The Left Understands RomneyCare
In defending his health care plan, former Massachusetts governor turned presidential candidate Mitt Romney never fails to call it a “free market” plan or to denounce “HillaryCare,” the presumed alternative. In the most recent Iowa debate, he proclaimed: “This is a country that can get all of our people insured with not a government takeover, without HillaryCare, without socialized medicine…. We [in Massachusetts] didn’t expand government programs.”
In reality, as my collegue Michael Cannon has pointed out, RomneyCare is virtually indistinguishable from HillaryCare. But don’t take our word for it.
Joe Conason of the New York Observer is the latest liberal advocate of national health care to note the similarities. As Conason says, “Actually, his fabulous Bay State plan is based entirely on governmental action, from mandating insurance coverage and minimum coverage requirements to subsidizing insurance and imposing fines on those who fail to comply.”
Romney has been trying to position himself as the “conservative” alternative to Rudy Giuliani and John McCain. But being a conservative Republican should be about more than abortion policy and the War on Terror. At the very least, supporting a government take over of one-seventh of the U.S. economy should disqualify one from being anything but the biggest of big-government conservatives.