Tuesday, November 24, 2009

David Brooks gins up another faux consensus

"It’s easy to get lost in the weeds," David Brooks warns, "when talking about health care reform." So Brooks, that genial guide, kindly leads readers off a cliff.

Declining to explain in any detail why he thinks the robust cost-control measures in the Senate health care bill would fail if enacted, Brooks relies instead on his two old stand-bys: mushy generalizations about values and recourse to faux consensus.

What a society gains in security through social welfare programs, Brooks declares without any evidence, it usually loses in vitality. There's a caveat:
Occasionally, our ancestors found themselves in a sweet spot. They could pass legislation that brought security but without a cost to vitality. But adults know that this situation is rare
Interesting to cast successful social welfare programs as the domain of our "ancestors." That projects such doings into a mythical realm, akin the age of prophecy that rabbis deemed to have ended after the post-exilic prophets. Needless to say, then, health care reform won't reach that state of grace. By enacting it, we will sap our vitality!

Perhaps in his next column Brooks can explain how dozens of wealthy countries that provide health care to all their citizens at half to two-thirds the per capita spending of the U.S. have sacrificed their "vitality." Or how subjecting tens of millions of Americans to subpar care and constant risk of financial ruin magically confers "vitality" on the U.S. -- rather than sapping it by chaining people to their current jobs, assuming they can hold them and that their employers do not scuttle or eviscerate their health plans.

According to Brooks, the great vitality drain will presumably be triggered when an enacted reform bill accelerates rather than controlling health care spending and thus redistributes wealth to the most vulnerable. To make this argument he relies on the device he used three weeks ago to prove that Obama lacked the grit to win in Afghanistan: conjuring consensus out of thin air. Here's how it works this time:

The authors of these bills have tried to foster efficiencies. The Senate bill would initiate several interesting experiments designed to make the system more effective — giving doctors incentives to collaborate, rewarding hospitals that provide quality care at lower cost. It’s possible that some of these experiments will bloom into potent systemic reforms.

But the general view among independent health care economists is that these changes will not fundamentally bend the cost curve. The system after reform will look as it does today, only bigger and more expensive.

As Jeffrey S. Flier, dean of the Harvard Medical School, wrote in The Wall Street Journal last week, “In discussions with dozens of health-care leaders and economists, I find near unanimity of opinion that, whatever its shape, the final legislation that will emerge from Congress will markedly accelerate national health-care spending rather than restrain it.”

Now, Dr. Flier is indeed a formidable authority. Doubtless he has spoken with many colleagues and experts as he claims. But his assertion of "near unanimity" is just that -- an assertion. Brooks leverages it -- without relaying Flier's substantive argument in any detail -- into "the general view among independent health care economists."

No such "general view" exists. I don't know of any WSJ-style survey of health care economists and experts. But there's good reason to believe that consensus is closer to the opposite view, as Ronald Brownstein suggests in a widely-cited article about expert response to Reid's bill. Here's a centerpiece of the feedback Brownstein reports "from the center to the left":
In their November 17 letter to Obama, the group of economists led by Dr. Alan Garber of Stanford University, identified four pillars of fiscally-responsible health care reform. They maintained that the bill needed to include a tax on high-end "Cadillac" insurance plans; to pursue "aggressive" tests of payment reforms that will "provide incentives for physicians and hospitals to focus on quality" and provide "care that is better coordinated"; and establish an independent Medicare commission that can continuously develop and implement "new efforts to improve quality and contain costs." Finally, they said the Congressional Budget Office "must project the bill to be at least deficit neutral over the 10-year budget window and deficit reducing thereafter."

As OMB Director Peter Orszag noted in an interview, the Reid bill met all those tests.
The Garber letter is signed by 23 leading economists, including two Nobel laureates, Kenneth Arrow of Stanford and Daniel McFadden of Berkeley. A third Nobel Laureate, William F. Sharpe, asked for his name to be added to the list of signers, according to the Harvard Crimson.

Brooks does not bother with the substance of Dr. Flier's argument. That argument boils down to three points: 1) the pending health reform bills are structurally similar to the Massachusetts quasi-universal coverage bill passed in 2006; 2) the Massachusetts bill has not slowed health care inflation, and 3) Massachusetts is just now turning its attention to serious means of controlling costs. Here's where the argument gets curious:

A "Special Commission on the Health Care Payment System" recently declared that the Massachusetts health-care payment system must be changed over the next five years, most likely to one involving "capitated" payments instead of the traditional fee-for-service system. Capitation means that newly created organizations of physicians and other health-care providers will be given limited dollars per patient for all of their care, allowing for shared savings if spending is below the targets. Unfortunately, the details of this massive change—necessitated by skyrocketing costs and a desire to improve quality—are completely unspecified by the commission, although a new Massachusetts state bureaucracy clearly will be required.

Yet it's entirely unclear how such unspecified changes would impact physician practices and compensation, hospital organizations and their capacity to invest, and the ability of patients to receive the kind and quality of care they desire. Similar challenges would eventually confront the entire country on a more explosive scale if the current legislation becomes law.

Selling an uncertain and potentially unwelcome outcome such as this to the public would be a challenging task. It is easier to assert, confidently but disingenuously, that decreased costs and enhanced quality would result from the current legislation.

So: Massachusetts has not yet worked out the details of serious structural reform. Those details -- and on this point there is something approaching a consensus, which appears to include Dr. Flier -- must be worked out incrementally, by trial and error. That is precisely what the Senate bill -- in contrast to the Massachusetts bill -- aims to do from the outset. Brownstein again, on the bill's measures to seed structural reform:
The other set of Baucus proposals were intended to promote more coordination among providers. These have survived almost verbatim into the final bill. The bill encourages groups of providers to establish doctor-led "accountable care organizations" to more comprehensively manage patients' care by allowing them to share in any savings for Medicare they produce. It also establishes a voluntary national pilot of "bundled" payments that would encourage hospitals, doctors and other providers to work more closely together. Another pilot program would test coordinated home-based care for chronically ill seniors.
Dr. Flier plainly does not think much of these measures. He asserts, without any detailed enumeration or assessment of them:
Likewise, nearly all agree that the legislation would do little or nothing to improve quality or change health-care's dysfunctional delivery system. The system we have now promotes fragmented care and makes it more difficult than it should be to assess outcomes and patient satisfaction.
Nor does Dr. Flier assess the likely effects of an empowered Medicare commission or of the excise tax on expensive plans. He may have excellent reasons, based on practice experience and discussion with colleagues, to believe that the package of cost control measures won't work. But he's content to merely assert them.

Brownstein relays what appears to me a more balanced, if hardly rapturous assessment:
Former CBO director Robert Reischauer, who signed the November 17 letter, says that's not surprising. "CBO is there to score savings for which we have a high degree of confidence that they will materialize," says Reischauer, now president of the Urban Institute. "There are many promising approaches [in these reform ideas] but you...can't deposit them in the bank." In the long run, Reischauer says, it's likely "that maybe half of them, or a third of them, will prove to be successful. But that would be very important."
And from Mark McClellan, Bush's director of the Center for Medicare and Medicaid Services:
McClellan, the former Bush official and current director of the Engleberg Center for Health Care Reform at the Brookings Institution, was one of the economists who signed the November letter. McClellan has some very practical ideas for improving the Reid bill (more on those below), but generally he echoes Orszag's assessment of it. "It has got all four of those elements in it," McClellan said in an interview. "They kept a lot of the key elements of the Finance bill that I like. It would be good if more could be done, but this is the right direction to go."

Brownstein's article was published three days before Brooks' and has circulated widely. But Brooks does not engage it -- or any other of the formidable health care experts who are voicing support for the Reid bill's cost control measures. Instead, he reverts to the tiredest and most circular of Republican talking points against those measures:
Moreover, the current estimates almost certainly understate the share of the nation’s wealth that will have to be shifted. In these bills, the present Congress pledges that future Congresses will impose painful measures to cut Medicare payments and impose efficiencies. Future Congresses rarely live up to these pledges. Somebody screams “Rationing!” and there is a bipartisan rush to kill even the most tepid cost-saving measure. After all, if the current Congress, with pride of authorship, couldn’t reduce costs, why should we expect that future Congresses will?
Ezra Klein has dealt nicely (and repeatedly) with the embedded logic of such critiques:

More broadly, I'm confused by the budget hawks who that take the line: "This bill needs to cut the deficit, and I don't believe Democrats will cut the deficit, but since the actual provisions of the bill unambiguously cut the deficit, then I guess Congress won't stick to it."

People who want to cut the deficit should support this bill, and support its implementation. The alternative is no bill that cuts the deficit, and thus no hope of cutting the deficit.

Klein has internalized the argument of Harvard's Jonathan Gruber - another signatory of the Garber letter -- who put it this way when he spoke to Klein:

We know we will be closer to bending the curve with this bill than without it. But we can't promise this bill alone will bend the curve. This bill moves us towards that. First is the Cadillac tax. Then comes more research on comparative effectiveness. We need to be able to stop paying for things that don't work. This bill doesn't do that, but it sets us up to have the information to do that. Then there's MedPAC on steroids. You need someone with the political ability to set rates to controls costs. Finally, this bill has pilot programs for a lot of things that we think will control costs, but that haven't been proven. Things like accountable care organizations, bundling and all the rest. We're at the stage where we know in theory what to do. But we don't quite know how to set it up, so we're collecting that evidence.

I think this is as much as you can do politically. It's as much as you can do without sinking the whole bill, which is what happened to every other health-care reform.

Finally, one more advocate of this kind of incremental approach to change is worth listening to:

At this point, I am confident that both the House and the Senate bills will contain what we've been calling MedPAC on steroids, the idea that you continually present new ideas to change incentives, change the delivery system, understanding that because this is such a complex system we're not always going to get it exactly right the first time, and that there have to be a series of modifications over the course of a series of years, and we have to take that out of politics and make sure that an independent board of medical experts and health economists are providing packages that are continually improving the system. So I think there's general consensus that that is one of two very powerful levers to bend the cost curve.

That's a certain Barack Hussein Obama, speaking to Fred Hiatt on July 26. A man whose M.O. is always to move the battleship by a few degrees.

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