JONATHAN CHAIT MARCH 11, 2011
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Jonathan Cohn, Paul Krugman, Ezra Klein, and Matthew Yglesias all marvel at the Republican view that (in Klein's phrase) Medicare and Medicaid cannot use studies measuring the effectiveness of different medical treatments when deciding what to cover or not cover. Yglesias formulates an explanation revolving around self-interest:
I see two ways in which it can be rendered coherent, albeit repugnant. One is basically the “welfare state for me, but not for thee” of old people. Any effort to reduce government spending on health care for the elderly is intolerable socialism, and any effort to increase government spending on health care for the non-elderly is also intolerable socialism. That’s cynical, but it also reflects the objective difference in the age structure between the parties.
Another way of looking at it is this. Currently Medicare is an unlimited commitment to pay for old people’s health care. Ultimately, that needs to be transformed into a commitment that is limited in some way. The Obama administration’s idea is to limit it technocratically, through comparative effectiveness research. The idea is that for some arbitrary level $X of taxpayer spending on health care, the funds will be allocated to the treatments with the highest cost-benefit outlook. Other treatments can be paid for out of pocket. The conservative alternative is to limit the commitment through high deductibles. The government will pay for whatever, but only if you’ve already spent $Y out of pocket. Since $Y will represent a higher share of your income the richer you are, this is a proposal that’s much friendlier to wealthy old people than to less wealthy ones.
I see explanation one as persuasive, explanation number two not so much. Even accepting the questionable premise that comparative effectiveness research will end up denying coverage for treatments that may be desirable (say, those that are slightly more effective at vastly higher cost), I don't see how ending that hurts the rich. The rich will pay for those treatments out of pocket, but the non-rich will not get those treatments at all. I don't see how that scenario should be thought of as "bad for the rich."
I think the other factor at work here is just very simply -- ideology. Conservatives do not believe that the government can rationally measure effective and ineffective treatments and steer funding away from the latter to the former. Or, rather, they begin with the premise that the market is the answer, and reject any solution that doesn't involve the market. Comparative effectiveness research is a solution to health cost pressure that involves bureaucrats. Therefore it can't work. Giving everybody "skin in the game," and assuming that patients will be discerning customers, lying on the emergency room table and requesting the intervention that makes the best use of their health care dollar, is a market solution. Therefore it will work.
Anyway, "keep the government off my Medicare" is a strong impulse among the base, and "patients, not bureaucrats, will figure out what treatments work" is a strong impulse among conservative elites. Now, conservative elites like to pretend that the base is more ideologically anti-government than it actually is. But ultimately the two strands dovetail pretty well politically.
11 comments
"patients, not bureaucrats, will figure out what treatments work" is a strong impulse among conservative elites
I think this is a strong impulse across the entire GOP, not just the elites. The elites are, once again, using the peoples' fear to make political hay for themselves. The problem is patients don't make many decisions beyond the yes/no variety in health care; the doctors tell them what they'll do for the patient, and the patient says yea or nay. This is sometimes because the doctor has already decided how the diagnosed is to be treated, or maybe because they don't know of any other treatment (all too common, as doctors don't always keep up to date on medical information and technological advancements once they begin their practice). But having at least the illusion of choice makes the people feel empowered and woe unto any politician who threatens that feeling.
- GSpinks
March 11, 2011 at 3:49pm
You say: "Conservatives do not believe that the government can rationally measure effective and ineffective treatments and steer funding away from the latter to the former." ... on the contrary, they DO believe it! They KNOW it will. They know government management will be more effective and the oligarchy will have less leverage to claim power. You still seem unwilling to assert the Republican mind is a criminal mind. Ideological motivation indicates some sort of intellectual honesty. And that is just not the case. All the evidence is there ... why do you resist?
- keepin_on
March 11, 2011 at 3:55pm
This has to do with more than "effectiveness research". We are often reminded that this is a "Christian nation". And what does a Christian believe? In the resurrection, in life after death for those who truly believe. Why, then, do so many Christians fear death, so much so they will do almost anything, spend any sum, to postpone it, rather than embrace death, as the culmination of one's life, not the end of it? Life. Death. "Effectiveness research" won't provide the answer. No better time than at the beginning of Lent for a Christian to consider his or her mortality, and to discuss end of life decisions with his or her family. That's what Jesus did with His "family".
- rayward
March 11, 2011 at 4:18pm
Yet, another piece of evidence that the Bernie Madoff generation is, as a whole, guilty of monumental hypocrisy. They have lived their lives with the benefits of the New Deal and Great Society and especially super progressive taxation of the rich (in the past). Now they wish to deny to everyone else what they got, because the right has played to their infinite sense of cultural grievance.
- MikeB.
March 11, 2011 at 4:20pm
I have a more parsimonious explanation. Conservatives oppose comparative effectiveness research because it contains the word "research."
- miceelf
March 11, 2011 at 5:12pm
You are on today. mice. You just sprung Ockham's Razor on us, in humorous fashion. You are as lost in epistemic closure as is much of the right, keepin'. The very wealthy, those worth $10 million and up, favored Barack Obama by a 2-1 margin in the 2008 presidential election. This datum alone blows up your worldview. The oligarchy, indeed.
- liberalref
March 11, 2011 at 7:03pm
Republicans oppose effectiveness research because it would conclusively set in stone the course of treatment of health issues that pharmaceutical companies, medical device manufacturers, enterprising specialist doctors, &c. would like to be able to determine through marketing, PR, salesmanship, &c. What happens if it turns out something mostly treated through Medicare with a $300/month prescription is provably better treated with a generic, or aspirin, or a certain diet, etc.? One person's inefficiency is another person's profit margin ...
- misterpibb
March 11, 2011 at 7:43pm
except that it would not necessarily set anything in stone. all the PPACA does is call for research. and any legit research is going to point out that in most cases there is a need for flexibility in course of treatment based on contingencies of each and every treatment. what it will do is make it impossible for hospitals to run up the patient's tab with superfluous diagnostic procedures, which is one of the known inefficiencies of the current system for which there is little that the government can do to prevent.
- GSpinks
March 11, 2011 at 8:59pm
The last factor is simply that Obama supported it so they have to oppose it. To be sure, the "you never know whether a given treatment is going to work for a given patient, so we should subsidize all treatments" argument is certainly wrong, but it isn't wrong in an especially right-wing way. In an alternative universe in which the right had pushed for more effectiveness research, I could imagine Michael Moore sorts demagoguing against it, arguing it was an excuse for insurance companies to kill poor people.
- WillPastor
March 11, 2011 at 10:17pm
Instead of calling it "comparative effectiveness research" why not call it "eliminating Medicare waste and fraud" which is essentially the desired result. The Republicans can't oppose that, can they?
- koppgeo
March 12, 2011 at 12:09pm
koppgeo - surely you jest, my friend. The gop will wet their pants with glee pinning that particular tail on the dem donkey for the next 18 months, getting seniors to see only "eliminating" and "medicare" in that sentence. Seniors will be happy to willfully forget this is the same republican party that wants to torpedo medicare and social security. If any seniors are on the ball enough to call the gop on their hypocrisy, Eric Cantor will simply remind them that Oceania has always been at war with East Asia, and that will be that.
- Tristan
March 14, 2011 at 9:34am