Conservatives hit the wrong health care reform target

Just as concerns about the end-of-life care provisions are overblown, the health reform bills will not lead to rationing in other settings. The bills stipulate a fairly generous, some might say overly generous, benefit package, and do not give added authority to Medicare or other government programs to deny care.

Likewise, there is no historical basis for the concern that reform will lead to stealth rationing or waiting lists. Medicare and Medicaid, both in their fourth decade, have not rationed care, and doctors are free to treat patients as they wish.

In focusing so much on rationing, critics are deflecting attention from the real danger lurking in health reform, which is out-of-control spending and budget deficits.

Far from restricting access to medical care, the reform bills will continue Medicare and Medicaid’s open-ended coverage policies, where every drug, surgery and device that shows a benefit is covered without restriction, no matter the cost.

The bills authorize funds for comparative effectiveness research to identify which medical procedures work best, but prohibit Medicare from using the results in coverage policies.

It is odd to see conservatives, who so forcefully advocated for subjecting environmental and workplace regulations to cost-benefit analysis during the Reagan and Bush administrations, argue that the same calculus should not apply to health care.

A more sensible coverage policy that considers costs and benefits could save money without significant adverse effects on health.

Conservatives have their own ideas about health reform — high-deductible health plans and health savings accounts, for example — but these would not resolve the central issue of how to balance costs and benefits in the treatment of seriously ill patients.

High-deductible plans always have an out-of-pocket maximum, the level beyond which insurance pays 100 percent of costs.

Patients receiving end-of-life care and patients treated with expensive chemotherapy regimens, the clinical scenarios that have received the most attention in the debate over rationing, will have long since exceeded the out-of-pocket maximum. They would be fully covered by insurance, and would thus have no incentive to economize on care.

Allowing patients to choose between competing private plans and requiring them to pay more if they select an expensive plan, a system known as “managed competition,” is a more promising path for reform. Private plans that offered a limited benefit package would be able to sell their plans for a lower premium and attract more customers.

Yet, even under managed competition, the government exerts a strong influence over spending and coverage policies by setting the minimum benefit package. It is difficult to remove government entirely from the coverage process.

In focusing so much attention on rationing, conservatives are gaining traction with the public. But they are selling future taxpayers short in the process. Whether reform passes or fails, the costs of the Medicare program will continue to grow on an unsustainable path.

What will conservatives say 10 or 20 years down the road when Democrats propose large new tax increases to pay for Medicare? By taking sensible reforms off the table, conservatives are now in the position of advocating for higher government spending today and, implicitly, higher taxes down the road.

David H. Howard is an associate professor in the Department of Health Policy and Management at Emory University.