Outside editorial: Irrational about health care rationing

Posted: Wednesday, November 10, 2010

The following editorial appeared in the Los Angeles Times:

The growing ranks of Americans without health insurance - more than 50 million, according to the Census Bureau's latest estimate - are a clear symptom of a dysfunctional health care system. A more subtle sign of trouble emerged just before last week's elections, when a blue-ribbon panel of doctors canceled a meeting to discuss guidelines for preventive care.

The 15 primary-care physicians who make up the Preventive Services Task Force, an independent group sponsored by the federal Agency for Healthcare Research and Quality, review the evidence about screening and other techniques for detecting and preventing disease, then advise doctors on which ones to use. The panel had been set to meet Nov. 1-2 to discuss, among other things, possible new guidelines for prostate and cervical cancer screening. But the meeting was called off, ostensibly because of scheduling conflicts.

One of the task force's staff members, Dr. Kenneth Lin, offered a different explanation on his blog. According to Lin, "the question of why the meeting was canceled is perhaps easily answered by looking at the calendar" - a reference to the meeting's proximity to Election Day. "Politics trumped science this time, as it has in the past," he added, linking "in the past" to a New York Times story about the controversy over the task force's recommendation that fewer women receive routine mammograms.

The backlash over the mammogram recommendation was so severe that the Senate amended the health care reform bill to require federal programs to disregard the change in the task force's guidelines. The panel could trigger a similar firestorm with the prostate screening guidelines. The task force reportedly voted last year to recommend against the tests for men of any age, but held off pending further study. It has yet to release a formal proposal for public comment.

These episodes illustrate what may be the biggest challenge facing policy-makers as they try to restrain the health care costs that are consuming so much of the country's resources. Americans have a hard time accepting limits on their access to care, even if the treatment or drug is shown to be ineffective. They're much more willing to put up with rationing by income, which the current system imposes by allowing wealthier people to buy more and better care, than accept even the whiff of rationing by the government.

Bear in mind that the task force doesn't try to determine whether screening saves money in the long run for patients, or even whether a particular test works better than other, less expensive methods. "Cost just isn't a consideration when the task force deliberates," Dr. Ned Calonge told the Washington Post last year. The panel simply tries to judge whether a prevention technique is medically effective. Nevertheless, a common, misguided criticism of the task force in the wake of the mammogram decision was that it was trying to cut costs, not improve medicine.

A similar theme has run through the criticism of the new federal health care law, which takes a few small steps toward promoting science-based medicine and more effective treatments. Republicans seem particularly eager to eliminate spending on research that compares the effectiveness of treatment regimens, evidently preferring to leave doctors in the dark than to lay a foundation for the government to stop funding some types of care.

It's fair to debate how best to achieve health care reform. But it's hard to see how health care costs can be brought under control if attempts to make the system more efficient and effective get waylaid by irrational fears about rationing.



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