Step right up to see the Amazing Health Care Reform!

If it wasn't so serious, it would really be funny.

Peter R. Orszag, director of the White House Office of Management and Budget, wrote an op-ed in the Wall Street Journal on Friday explaining the urgency of reforming health care in the United States, and how President Obama proposes to move us "toward a high-quality, lower-cost system":

Much of the piece is a number-crunching whine about the unsustainable growth in the cost of Medicare, but the severity of a problem is not an argument for the efficacy of a proposed solution.

The solution proposed by the Obama administration is so offensive, obnoxious and un-American that no amount of whining about the severity of the problem will persuade anybody in the country to support it. The only question now is whether the organized interest groups that have prepared for this match-up will have to play the full nine innings, or whether they'll win on the slaughter rule.

"There are four key steps," Mr. Orszag explains:

1) health information technology, because we can't improve what we don't measure; 2) more research into what works and what doesn't, so doctors don't recommend treatments that don't improve health; 3) prevention and wellness, so that people do the things that keep them healthy and avoid costs associated with health risks such as smoking and obesity; and 4) changes in financial incentives for providers so that they are incentivized rather than penalized for delivering high-quality care.

Let's take these one at a time.

"Health information technology, because we can't improve what we don't measure." What he's talking about is digitizing everyone's medical records and transmitting the information to the U.S. government. Is it private? Is it secure? Is it accessible to snoopy government workers who'd like to pick up some extra money from the National Enquirer? For the sake of argument, let's grant the ridiculous premise that the government solves the problem of security. Do you want the government collecting and reviewing your medical records? Is it any of their business?

"More research into what works and what doesn't, so doctors don't recommend treatments that don't improve health." Unless you believe that people go to medical school to become golfers or murderers, you are probably wondering why a government budget official thinks doctors would recommend treatments that don't improve health. Doctors go through some of the most rigorous training of any profession in the United States. Peter Orszag believes that a government computer that collects everyone's medical records and crunches the numbers to determine the most successful "outcomes" is better suited than your doctor to determine the best course of treatment. Is that what you believe?

"Prevention and wellness, so that people do the things that keep them healthy and avoid costs associated with health risks such as smoking and obesity." This may not trouble the Obama administration, but a lot of Americans will object to the government demonizing them for smoking or wearing plus-size clothes. Is it any of the government's business what you eat or what you smoke or whether you drink or exercise? How much of this nanny-ing will Americans tolerate? Not too much, history suggests. The Republican Congress elected in 1994 began by ending the 55-mph speed limit and ended by banning online poker.

"Changes in financial incentives for providers so that they are incentivized rather than penalized for delivering high-quality care." By this Mr. Orszag appears to refer to the practice of paying doctors per procedure instead of per "outcome." Elsewhere in the piece he writes, "The president's budget also put forward a set of quality-enhancing changes in incentives in Medicare and Medicaid, such as paying hospitals less when they don't get patient treatment right the first time so we can reduce the number of patients who have to endure readmission to a hospital."

This is very disturbing. The premise here is that people are readmitted to a hospital only because the hospital didn't get the treatment right.

But medical treatment is not a right-answer versus wrong-answer question. It's a complicated, difficult task of evaluating competing risks and possible consequences. Patients don't always come into a doctor's office with a clean bill of health and one new problem. They have conditions and risk factors that make medical decision-making an enormous challenge for even the most experienced and skilled professionals. You've heard the lists of side-effects on those prescription drug commercials, right?

What Peter Orszag calls "a set of quality-enhancing changes in incentives" is a destructive, maybe deadly, interference with a doctor's best judgment about the right treatment for the patient in the office at that moment.

No government bureaucrat, no matter how smart, is qualified to dictate treatment decisions to any doctor, no matter how inept.

Then there are the unintended consequences.

One practical effect of paying doctors only for "good" outcomes will be a hideous, horrible medical system that forces seriously ill patients to search in vain for a doctor who will treat them. "Sorry, not taking on any new patients," is the answer that will be thrown in the face of a desperate patient seeking a second opinion or a last chance. If the outcome isn't likely to be "good," a doctor risks his own career and practice by lowering his quality "score" in the government's computers.

Maybe there soon will be more dermatologists and fewer cancer specialists.

Yes, and maybe pink elephants will climb to the top of the Washington Monument. None of this is going to happen because no matter how much the Obama administration insists that this must all be done by August, none of this is going to pass Congress.

And it shouldn't pass Congress. "Hurry, hurry, hurry" is the call of a carnival barker. What you see when you get inside the tent is never as good as it looked on the poster.

Copyright 2009

Editor's note: You might be interested in the earlier post, "Insanity."

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