The Power of Saying 'No'
In today's New York Times, David Leonhardt argues that deep down, Americans tend to view more health care as better care, but that in our quest for the best care, more care can actually mean worse care. One of our colleagues at the New America Foundation, Shannon Brownlie, argues that Americans are actually overtreated, recieving enormous amounts of care that often does little to improve our health (read about her book Overtreated here).
Leonhardt discusses how the "try-anything-and-everything instinct" in health care is ingrained in our culture. While this approach has big potential payoffs, there are also dangerous and costly downsides to more agressive treatments -- and we need to learn how to sometimes say "no" to more (and more costly) care. But those who argue for some of these less costly and invasive treatment options often confront bitter opposition through accusations of rationing and being "soulless."
We warned in a previous policy paper, Principle #1: Slowing Health Care Cost Growth, that most experts cite the emergence, adoption, and proliferation of new health care technology as the main driver in cost growth, and that if we are to get our fiscal house in order, health care cost growth would be the single most important factor:
"Bending the cost curve will likely result in the slower adoption of new health care technologies. Although studies have shown that many new technologies do not add sufficient clinical benefits to be worth their costs, it is likely that more cautious technological adoption would cause some potentially valuable drugs and procedures to never be developed."
"...To the extent that we as a country are not willing to accept these changes or find others, higher health costs will necessarily come at the expense of other priorities. For the federal government, in particular, this will mean raising taxes, reducing the public role in providing health coverage, and/or cutting spending elsewhere in the budget. These fundamental trade-offs cannot be avoided. However, by making the health care system more efficient and cost conscious, we can reduce health care costs relative to their current path. This is the single most important thing we can do to restore long-term fiscal stability, and it must be at the center of any health care reform plan."
Leonhardt contends that learning to say no to more health care will be a three step process, and that health care reform can help all three:
Learning more about when treatments work and when they don't. The Institute of Medicine found that "all too often data in incomplete or unavailable." To help increase comparative effectiveness research, the health care reform act a new Patient Centered Health Research group will have $600 million each year to fund such research.
Give patients the available facts about treatments. Leonhardt cites some early evidence that when patients are given information about potential benefits and risks of certain treatments, they tend to choose less invasive care than doctors do. To increase patients' access to treatment information, the health care reform act requires Medicare and other health agencies to help give patients more information.
Change the economics of medicine. To help reduce health care cost grow, our system must reward better care rather than more care. Under the health care reform act, tax subsidies for insurance will slowly decrease, which Leonhardt believes should help people realize that health care is not free.
In a book titled Can We Say No?: The Challenge of Rationing Health Care, health experts Henry Aaron and William Schwartz note the double-edged sword of modern medicine, while not downplaying the tough choices that rationing will force us to make if we are to have a prosperous nation:
"The good news is that modern medicine works miracles. The bad news is that it breaks banks -- public and private."
"...The choices are clear. We can simply pay the enormous bill for all beneficial medical care whatever the cost. Or we can ration...Rationing will inevitably be controversial and difficult to implement, but like bitter and efficacious medicine, it can be good for our nation's health."
Grappling with whether we can say no to people for more health care, we must also consider the hard choices we made in saying no to taxpayers through the health care act. Included in the act are excise taxes on high cost insurance plans and decreasing tax breaks on employer provided insurance, factors that should put downward pressure on costs over time. As we argued in a recent paper, Principle #5: Continued Vigilance in Health Reform, there will be political pressures to remove these cost-reducing policies in the future.
But if we are serious about controlling health care costs and the growth of federal debt, we must learn to say "no" and how to spend what resources we have more effectively. Budgeting is all about tradeoffs -- we must realize that by paying more for less effective health care we are giving up greater spending and tax breaks for other programs in the long-term.