Breast Care Scare - A Harbinger

In the confusion and tumult surrounding the health care reform debate, there came a flare in the night, so to speak, a signal or omen, ominous in nature, that shed a bright light on the matter of government monopolized medicine, that small incendiary being the upending of protocol regarding screening mammograms for breast cancer.  Suddenly, it seemed, the outlines and contours of some future version of Obamacare appeared in bold relief, and, for a moment, the headlines were ablaze with this portent of things to come, the anticipated waiting lists and rationing, of remote government panels or bodies making medical decisions from afar, inserting themselves between patient and physician. 

Obamacare opponents have long raised this eventuality, understanding fully that single payer must inevitably ration once unlimited demand confronts limited resources in an already hopelessly distended federal budget.  Healthcare reformists, on the other hand, vigorously refute this, denying that which has occurred in every government health care system in the world.  How else to control costs with so vast an entitlement?  Borrow from the Chinese forever?  But, then, balanced budgets, fiscal continence, and living within one's means, have been of only peripheral interest to the lords and barons and kings inhabiting the halls of Congress and the White House. 

It has been a staple of preventive care that women perform periodic breast self-exams, and for those over 40, to undergo annual or biennial mammograms for early breast cancer detection, a disease that takes the lives of 40,000 individuals every year.  New guidelines, however, from the Health and Human Services Departments' US Preventive Services Task Force (USPSTF), overturning its own 2002 directives now advise that women of average cancer risk in their 40s no longer need mammograms, and that woman between the ages of 50-74 undergo mammograms only every other year.  It also advises that physicians stop teaching breast self-exam (because, reputedly, of a lack of evidence that it helps) and that woman 75 and over no longer need bother with routine mammograms.  The new guidelines are based in part on weigh some of the benefits of early screening with some of the risks such as false positives, which leads to additional unnecessary testing and anxiety.  The 2002 guidelines, on the other hand, advised mammograms every 1-2 years for all women older than 40 and were agnostic on the matter of breast-self exam.

Breast Cancer is the second leading cancer killer of women.  Since mammograms became routine in the nineties, the mortality rate for breast cancer has dropped by 30% based in part on early detection.  And, so, a pronouncement that women under 50 and over 75 without certain risk factors no longer require screening came as a bombshell.

The outcry, of course, was immediate.  Chief among the concerns was the possibility that private insurers, embracing the new guidelines would no longer cover mammograms for women in their forties.  There is also the danger that Medicare and Medicaid, already bursting at the seams, would eventually climb on board, cutting off access to heretofore available screening mammograms of at-risk age groups.  Would the progress made in early detection and hence cures for breast cancer be compromised? 

There is also the questionable assumption that ladies would somehow prefer avoiding some anxiety and additional testing over a false positive more than taking a chance on missing the big one - cancer.  Overall, I would imagine most women would take their chances with early detection - and deal with the anxiety of a false positive.

We learn further that the task force included no oncologists or radiologists (those most familiar with the medical literature pertaining to breast cancer screening), and performed its analysis with spending as its primary focus.  As the Wall Street Journal reports, 1904 screenings were required to save a single life for women in their 40s and only 1,339 for women in their 50s; an additional 665 mammograms were, therefore, needed to save the same single life of women in their 40s.  Based on that comparison, the panel decided that it was not worth performing the screenings for that age group, even though 40% of patient years of life saved are in women in their 40s.  And, of course, for that one individual, it makes all the difference in the world.  The suggestion to end screenings for women over 75 is similarly troubling.  The logic here seems to be that since the elderly will die of something fairly soon anyway, why waste valuable resources saving elderly women from one of the leading killers of elderly women?

One can also easily imagine how a future "task force," on the basis of cost and budgetary pressure, could again "update" recommendations so that women over the age of 65 (instead of 75) may be advised against regular mammograms; or, that, perhaps, no one should have them, other than those with special risk factors; after all, cost pressures will only increase with time not decrease, and there will still be large numbers of "negative" studies (deemed "wasteful and unnecessary") performed on disease-free individuals before detecting the single "positive."  This all falls under the rubric of cost containment or, more accurately, "rationing," which describes accurately the inevitable outcome of nationalizing health-care. 

Rationing comes in many forms: it may be revised "guidelines" issued by "expert" panels, long delays and waiting lists, price and use controls for pharmaceuticals, devices, and procedures, bureacratic inefficiency, and various compulsory "edicts" delivered by "health councils" or "czars" with an eye to the bottom line.  Such decisions, however, have historically been made between the patient and physician, not a panel of "experts" in Washington.  One wonders what other guidelines will be discarded or modified by government bureaucracies based not on patient safety but cost, aggregate spending, and group averages when limited tax dollars crashes up against fiscal realities?

And what of unelected, cloistered bodies, the assorted "experts," bean counters, lawyers, and wonks, holed up in government offices making medical decisions, deciding which pharmaceuticals, imaging studies, and technologies to approve or deny?  Who is eligible and who is not?  And at what age?  How much to spend on a given individual?  Most of our health care resources, for example, go to end-of-life care for the elderly and severely ill.  How much are we willing to spend for sustaining life a relatively short time? 

There is also the matter of so-called "best practices," guidelines provided by experts that can, perhaps, be helpful but can also limit innovation, fail to take into account individual circumstances, appreciate the patient's own unique disease process and biology, and undervalue how medicine, as with all science, advances in fits and starts, by trial and error, or, indeed, by bucking consensus (ie. "guidelines"), and that what is held to be "best practices" today, may become obsolete and harmful a few years later.  It is in someways a dumbing down of medical practice, a "cookbook" approach; as "best practices" can provide useful guidance, they can also inhibit progress, prevent necessary experimentation, forestall breakthroughs, impede creativity and invention; they are not, in other words, mandates from Mt. Olympus; they are snapshots of a given moment in the evolution of current medical thinking on a particular medical issue; they can themselves lead to adverse outcomes if followed blindly and specific cirmcumstances and individual disease processes are not taken into consideration.

In a speech last September, Obama spoke of a panel of experts he sought to create, the Independent Medicare Advisory Council or IMAC, who would be "charged with identifying more waste in the year's ahead."  Even Democrats are getting nervous about looming debts, and, in particular, Medicare, with its $37 trillion unfunded shortfall over the next 75 years.  Their answer is an unelected commission that will make medical decisions based in large measure on the basis of cost, in an era of limited resources and exploding demand.  This has been the history of virtually all government giveaways; they are simply unsustainable in the long run and Medicare most of all, given enough time, threatens to consume the entire federal budget. 

But heaven forbid, Obama and the Democrats would consider a market based solution, such as providing vouchers for seniors to pay for their own insurance, increasing the single-buyer market, incentivizing seniors to seek out the best value for their money within a limited budget (as is done with the highly successful Medicare Advantage) and forcing companies to compete for their business.  In other words, allow Americans to do what they do in every other aspect of the economy, which is to comparison shop for the best deal, which drives down costs and increases competition.  But, no, Obama would prefer his "panel of experts" to decide what is best for you instead.  In an interview with the New York Times last April, Obama said that a panel like IMAC, working outside of "normal political channels," could make decisions regarding that "huge driver of cost... the chronically ill and those toward the end of their lives..."

And so it should come as no surprise that physicians and patients, particularly the elderly and sick, would raise serious concerns about such panels, invoke the obvious specter of "rationing," which is what all government controlled health care systems inevitably do.  Although there is no specific body or entity in any of the Health Care proposals referred to as "death panels," when limited resources confronts escalating demand, something akin to "death panels" is what you get.  Those most likely to be denied access or face "rationing" would be the very sick and the elderly, precisely because they are most likely to consume large amounts of health care resources and offer the least in terms of productive years.  When budgetary pressures build and spending caps are met, something will have to give; it then becomes a matter of resource allocation: those least likely to be "useful" to society and most costly to maintain will be the ones denied care, which is what happens in government plans.  All of it, ultimately, in any nationalized health care system, will be decided by unaccountable bureaucrats.

The Senate Finance Committee, in developing its Health Care Bill, envisions just such a "commission" that will produce a "global budget" for Medicare.  It will limit Medicare growth per capita to the rate of inflation and ultimately to the GDP plus one percentage point.  The commission's decisions would go into effect automatically if Congress cannot agree on spending cuts that meet budget targets within six months.  For now, the Commission can only go after Medicare Advantage, the popular private Medicare program (not liked, of course, by Democrats), but in 2019, the Commission will assume responsibility for all of Medicare, which means rigid budget caps.  It will of necessity go after the most expensive treatments; it will have to deny care to those most in need; it will suppress innovation and research, which after all, are often quite costly.  Such a commission will represent a radical shift in the way medicine is practiced in this country.  The emphasis will be on what budget cutting technocrats decide and not physicians and researchers.  Breakthrough medicines, new procedures, innovative technologies, devices, and equipment will all go the way of the buggy whip, deemed too expensive and unpredictable by a commission charged by Congress to keep Medicare spending from spiraling out of control. 

Again, let me suggest other less coercize, top-down, centralized approaches: in other words, the same system used in every other aspect of the economy: the free market.  Put patients in charge of their own health care by providing vouchers to purchase their own private insurance, looking for the best value at the lowest price, thereby increasing competition through normal free market mechanisms - comparison shopping, price transparency, expanding the single buyer market, pitting insurance companies (and, yes, across state lines) against one another.  Does it not occur to our Washington elites that in the realm of say computers, cell phones, cd or dvd players or any rapidly expanding aspect of the private economy, the power and sophistication of such new devices increases exponentially while the price goes down - amazing!  It is called, for those of you in government, capitalism.  The same phenomenon can occur in the world of medicine if we would but consider the application of free market mechanisms within it.  A vast new universe of agencies and bureaucracies with czars and commissions and global budgets is simply not needed.  No other aspect of the economy is run this way, what is so special about health care that the government must intercede? 

In Great Britian, the National Health Service has a mega "expert panel" or body known as the National Institute for Health and Clinical Excellence (NICE), responsible for determining "best practices."  It has also come up with an acronym known as "QALY" for quality adjusted life years.  It is based on a complex algorithm that limits the amount of money the state will spend to extend an individual's life six months to $22,000.  So, if you happen to be elderly and/or very ill, and it appears that the cost of extending your life six months will cost more than $22,000, you're out of luck.

The last six months of life is a difficult time under any circumstance, but imagine the additional turmoil in confronting such government imposed limits; and particularly at so painful a period, shouldn't such decisions be left to the patient, family, and physician rather than a "board of experts" in Washington (or London, as it were), making arbitrary decisions about life and death?  While it is true that insurance companies will deny care in some cases, it is based on prices and not coercion.  And there are generally other options.  There are myriad different insurance companies.  No one insurance company has dominion over the nation as the government does.  Its decrees or guidelines are not universal and can be challenged.  Doctors and patients and even the government can intercede.  There is "peer to peer" review and an appeal process.  You can take your story to the press if necessary and exert pressure that way.  If worse comes to worse, you can always pay for it.  But, at least, a particular treatment is available.  In centralized plans, only government approved treatments, technologies, and devices (stents, MRIs, monitors) will be accessible.  A private insurance system will generally maintain a far greater degree of experimentation and choice than a single payer system.

As we have seen with the recent changes in breast cancer screening guidelines, and as we have seen with the National Health Service in Great Britain, it is an unelected, unaccountable panel emphasizing cost containment, issuing guidelines and making medical decisions.  And, the main cost driver is the elderly and sick.  Although there is no specific mention of "death panels," as cost pressures rise, inevitably expert panels will ration care by limiting access to treatment for those deemed too costly to maintain.

Currently, the USPSTF revised guidelines are simply recommendations and not compulsory.  They are bad medicine, basically, that will increase mortality for one of the leading killers of women.  It also demonstrates an undervaluing of preventive care.  It is a decision that may benefit the government but not the individual.  Still, at this time, they are mere suggestions from one particular body.

But, should a health care plan pass bearing any resemblance to current House or Senate bills, look out for a NICE equivalent with coercive power coming your way; with unelected bureaucrats making life and death decisions, deciding arbitrarily who gets what and for how long, in effect who lives and who dies - not you or your doctor.

The complexities of health care must surely rank somewhere above overseeing the mortgage industry or the US Postal Service, neither of which the government has been very adept at, and yet the conceit of the political class is such that despite their many failures at administering any number of programs (Social Security, Medicare, Medicaid, Fanny and Freddie, etc.) they still seek to regulate and manage the entirety of our health care system, one sixth of the economy.

Who will deliver us from our government?