I took Obama's "blue pill" -- and got maybe 90% of "red pill" benefit....

In his health care press conference tonight, Obama stressed repeatedly that most "sacrifice" required from health care cost reduction should come from "sacrificing" unnecessary and ineffective treatments -- which makes sense when you consider that Americans spend in the neighborhood of 70% more per capita on health care than citizens of other wealthy countries without gaining any better outcomes. He went so far as to spell out that doctors in the U.S. too often have financial incentives to prescribe unnecessary treatment.

Personal experience leads me to quibble, though, with one of his examples of wasteful care, which made cost-benefit decisions seem cost-free. He said, “If there’s a blue pill and a red pill, and the blue pill is half the price of the red pill and works just as well, why not pay half price for the thing that’s going to make you well?”

As it turns out, my own highly competent and socially responsible primary care physician some time ago prescribed generic Simvastatin to bring down my cholesterol. It didn't work well, though later conversation revealed that occasional 1-2 week gaps that I let slip between prescription refills may have been responsible. When a checkup revealed that my cholesterol levels had not improved, I asked her if I wouldn't do better with Lipitor. She said that Lipitor, which is not available generically, would cost me much more (and she might have added, cost the insurer much more), and "only" deliver perhaps a 5-10% advantage. (While writing this, I checked that estimate out, and found a Pfizer report touting a study result purporting to show a 14% advantage for Lipitor over competitors, including Simvastatin. This was a "report" that read awfully like a Pfizer press release on a site of dubious provenance, with no "about" section.)

Assuming that my doctor was roughly right about the 5-10% Lipitor advantage , this was exactly the situation that Obama sketched -- except that there was a genuine cost-benefit choice to be made. Would a modest improvement in drug performance be worth an additional $20/month to me - and God knows how much to the insurer? That's a very complex calculation; variables include my age, the extent to which my cholesterol numbers were worrisome, and my overall cardiovascular profile (e.g., a C-reactive protein test that yielded a good result); whether my insurer should have paid for that test is a whole other question). I am currently trying again with Simvastatin.

Were I on Medicare, would an empowered MedPac oversight panel making decisions about what treatments to fund approve prescribing Lipitor to me? Would the doctor have any incentive to say, 'first try taking your Simvastatin regularly'? And it would be nice if someone wouldmandate that my insurer allow me to buy a three-month's supply at a time, so I'd be likelier to refill on time.

Obama himself has pointed out in other contexts that bringing medical costs under control will ultimately entail more agonizing choices. Here is an April 28 exchange with David Leonhardt, foreshadowing the MedPac proposal:

Now, I actually think that the tougher issue around medical care — it’s a related one — is what you do around things like end-of-life care —

LEONHARDT: Yes, where it’s $20,000 for an extra week of life.

THE PRESIDENT: Exactly. And I just recently went through this. I mean, I’ve told this story, maybe not publicly, but when my grandmother got very ill during the campaign, she got cancer; it was determined to be terminal. And about two or three weeks after her diagnosis she fell, broke her hip. It was determined that she might have had a mild stroke, which is what had precipitated the fall.

So now she’s in the hospital, and the doctor says, Look, you’ve got about — maybe you have three months, maybe you have six months, maybe you have nine months to live. Because of the weakness of your heart, if you have an operation on your hip there are certain risks that — you know, your heart can’t take it. On the other hand, if you just sit there with your hip like this, you’re just going to waste away and your quality of life will be terrible.

And she elected to get the hip replacement and was fine for about two weeks after the hip replacement, and then suddenly just — you know, things fell apart.

I don’t know how much that hip replacement cost. I would have paid out of pocket for that hip replacement just because she’s my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model, is a very difficult question. If somebody told me that my grandmother couldn’t have a hip replacement and she had to lie there in misery in the waning days of her life — that would be pretty upsetting.

And it’s going to be hard for people who don’t have the option of paying for it.

THE PRESIDENT: So that’s where I think you just get into some very difficult moral issues. But that’s also a huge driver of cost, right?

I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here.

So how do you — how do we deal with it?

THE PRESIDENT: Well, I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through the normal political channels. And that’s part of why you have to have some independent group that can give you guidance. It’s not determinative, but I think has to be able to give you some guidance. And that’s part of what I suspect you’ll see emerging out of the various health care conversations that are taking place on the Hill right now.

Difficult choices notwithstanding, American health care practice is rife with overprescription of scores of tests, operations, drugs and other treatments of dubious value, or of value only a fraction of the times they are prescribed. Don't get my wife, a nurse midwife, started about amniocentesis, a procedure usually about as valuable as a trip to the Oracle at Delphi. Not to mention Caesarian sections, which at her hospital are performed on something approaching 40% of births.

P.S. Leonhardt must have crowed tonight to hear the President adopt the lede from Leonhardt's 7/22 front page article, which framed the President's communication challenge as explaining to the American people re health care reform, what's in it for me? In his prepared remarks, Obama used the very words:

I realize that with all the charges and criticisms being thrown around in Washington, many Americans may be wondering, "What's in this for me? How does my family stand to benefit from health insurance reform?"

See also:
Massachusetts Commission cuts the Gordian Knot on healthcare costs
Leonhardt seconds Gawande: put doctors on salary
Orzag hones in on doctors' incentives

The Lipitor Election

For a moment this morning, I stepped back from thinking about the individual candidates and let a surge of hope for the country as a whole wash over me. Like most Americans, I've felt that the country has gone off the rails in recent years -- in preemptive aggression, massive tax cuts and deficits, a tenfold increase in lobbying, and, most importantly, in the Bush Administration's shredding of the Bill of Rights and assault on the separation of powers. I thought, 'the great virtue of a democracy is that it can self-correct -- as long as it's still a democracy. But are we?'

Doors were slamming on multiple avenues of choice and change. Start with the K Street Project, an enterprise corrupt to its core and breathtaking in its arrogance. Think about the premise - to coerce lobbying firms into hiring agents of one party only and to contribute to one party only. That's not only pay-to-play, pure and simple, but a move toward a one-party state. Couple that with ever more radical gerrymandering techniques, a national Rove-led attempt to disenfranchise as many poor voters as possible in the name of stopping imaginary 'election fraud', the selective prosecution of Democratic elected officials, the stacking of the judiciary with right wing ideologues who would support the power of the state at every turn. Then pile on the Bush Administration's assertions of unchecked executive power - in signing statements that negate key parts of laws passed by Congress, in twisted legal documents that assert the President's right to abrogate any law in the name of national security, and in the assumed power to deem anyone the executive branch chooses an "illegal combatant" who can be detained indefinitely and tortured at will.

You had to wonder: could restrictions on media freedom and assertions that Administration critics were security risks and ultimately "illegal combatants" be far behind? (Bill Kristol, who called for the NYT to be prosecuted for breaking the warrantless wiretapping story, was fired up, ready to go.) The path to step-by-step demolition of democracy was nicely marked out by Vladimir Putin, embraced as a soulmate by Bush.

Those dangers are still real. Elect a Giuliani or a Romney, and who knows what new executive powers they would seize in the wake of a major terrorist attack? But in the interim, democracy has struck back. A self-correction is in mid-course. Political choice remained real enough, and the media free and robust enough, to make it clear to two-thirds of the country that we were led to war on false premises; that the war was disastrous to our national interests; that the nation was being bankrupted to fund tax cuts for the wealthy; and that the environment was being terminally neglected. And so, in 2006, despite all the gerrymandering, the imbalance (over many years prior at least) in campaign funds, the 95% incumbency return rates, we had enough of a turnover to change the balance of power. On a state level, changeovers in legislatures and governorships reduced the overall power of Republican assaults on voter eligibility and equal access to polls.

Now, say what you like about this primary season, the choices are real and manifold; the debates have their moments of lucidity amid all the idiocy; money has been proved already not be decisive, and there is no way anyone claim that the results are not in the hands of voters. In the general election, there's still a danger that the electoral college or faulty voting equipment will skew the results. But those dangers (substituting old-style ballot box fraud for dicey electronic equipment) are as old as the Republic.

The electorate is smarter than all of us. That dawned on me about a dozen years ago, while I was reading a biography of Eisenhower; it occurred to me that I probably would have voted for Stevenson as my parents did, and I would have been wrong. Later I came to feel the same way about Reagan - who did not 'cause' the Soviet Union's breakup but certainly midwifed it, smoothed the glide path, gave Gorbachev the running room to do the job. So the electorate is at least smarter than I am, and I'm no dumber than the average voter.

That's not to say that the electorate doesn't make mistakes (sometimes pushed over the edge by our creaky Constitutional machinery) , just that it always eventually corrects them -- as long as the arteries of choice remain unclogged enough for information to flow.

Plaque builds slowly; our hearts can function with up to 95% blockage (as Bill Clinton's did just prior to his quintuple bypass). Democracy is resilient (if ultimately killable) like that. Sweeping statements that we're not a democracy because of lobbying, or incumbency, or widening income gaps are false as long as there's enough 'democratic function' to change course. I can see a descent past that line. But we're not there yet.

Short of a terror-induced executive power grab, the greatest threat to democratic functioning is the proliferation of lobbying. The most important chord in Obama's aria melody might be his promise to change the rules of the game so that lobbying is held in check. Edwards of course also promises to "take on" "lobbyists", but the weakness there is personalizing the battle, as if the problem will go away if an evil coterie of individuals is smitten. On this question Robert Reich's Supercapitalism is helpful. According to Reich, the escalation in lobbying is a function of supercapitalism, i.e. the hypercompetition in which each company and industry strives for competitive advantage on the legislative front (as in every other arena). Companies lobby not because they're conspiring to squeeze out the public interest, but to fend off rivals' attempts to gain advantageous legislation. The result is near-complete corruption of the legislative process as companies compete to buy legislation. The good news is that corporations are not reveling in this relentless arms race. Changing the rules of the game may be in everyone's interest.

Obama and McCain may both have the will and the skills to do this. Both have had more than one success on this front. Another day, another post for that one.