Obama-Daschle health plan

Obama/Daschle health care was just passed by the Senate in the so-called “Stimulus” bill.

What was that?

Did I say a health care program was in the Stimulus bill?

Yup. Sure did.

In fact, the Stimulus bill creates an entirely new federal agency within the Department of Health and Human Services. It’s called the “Office of the National Coordinator for Health Information Technology.” 1 The bill goes on to state that “the Office shall be headed by a National Coordinator who shall be appointed by the Secretary and shall report directly to the Secretary.” 2

Ah, you say, “You are referring to an article just published at Bloomberg.com by Betsy McCaughey and she is not well respected by good liberals. Moreover, I just read Wikipedia’s write-up on her and it makes it pretty clear that much of her article is just plain wrong. It says that President Bush created this position several years ago in an Executive Order, so nothing is new or radical in this bill.” Well, if you said that, you’d be wrong. And I’d also tell you to re-read the full write up; it now has my comments that correct errors of the author in the original post. (Interestingly, I have learned that Wikipedia is full of liberal moderators as portions of my corrective post have been deleted!)

Anyhow, President Bush’s Executive Order (EO) 13335 states:

Section 1. Establishment. (a) The Secretary of Health and Human Services (Secretary) shall establish within the Office of the Secretary the position of National Health Information Technology Coordinator. (Emphasis supplied) 3

EO 13335 established “the position,” not the “Office.”

In contrast, the Stimulus bill states, on page 441:

SEC. 3001. … (a) ESTABLISHMENT.—There is established within the Department of Health and Human Services an Office of the National Coordinator for Health Information Technology … . (Emphasis supplied). 4

It is a meaning with a distinction. A “position” is a job. It’s one person. “Office,” on the other hand, refers to:

Noun 1. federal office – a department of the federal government of the United States, department of the federal government… – a department of government  5

Moreover, the “position” created by President Bush, according to Section 3 (v) of EO 13335, was designed to “Not assume or rely upon additional Federal resources or spending to accomplish adoption of interoperable health information technology.” Under President Bush, the position did not require an increase on the national debt. There were no new taxes.

In contrast, the “Office” created in the Stimulus bill provides considerable funding:

$700,000,000 for comparative effectiveness research: Provided, That of the amount appropriated in this paragraph, $400,000,000 shall be transferred to the Office of the Director of the National Institutes of Health … to conduct or support comparative effectiveness research: . . . In addition, $400,000,000 shall be available for comparative effectiveness research to be allocated at the discretion of the Secretary of Health and Human Services … : Provided, That the funding … be used to accelerate the development and dissemination of research assessing the comparative effectiveness of health care treatments and strategies, including through efforts that:

(1) conduct, support, or synthesize research that compares the clinical outcomes, effectiveness, and appropriateness of items, services, and procedures that are used to prevent, diagnose, or treat diseases, disorders, and other health conditions; and (2) encourage the development … forms of electronic health data that can be used to generate or obtain outcomes data: 6 (Emphasis supplied).

Aside from the fact that the numbers in the above paragraph do not seem to add up, and thus it’s unclear to me if we are talking about more than $700,000,000 or simply a measly seven hundred million dollars. Either way, it seems like one hell of a good way to spend a king’s ransom to hire a federal agency to compare the effectiveness of treatments on a cost-benefit basis—precisely the type of activity for which the free market is uniquely qualified—and can to do all by itself, free of charge.

For reasons that are simply beyond me, and ought to be beyond everyone at this point, I have seen liberals argue that “The bill gives the Office of the National Coordinator for Health Information Technology no duties to review actual treatments.” 7 Apparently, liberals are afraid that we will see that the Emperor has no clothes, which is really quite a strange affliction for an empire so well funded.

But it is not simply hundreds of millions of dollars going down the crapper. No—No—No! All this money will buy something perhaps more insidious than is the expenditure of money we don’t have for something that we don’t need (or if we do need, something that the free market will do, and in fact does, on a daily basis free of charge. This new agency will, according to Betsy McCaughey, 8 “monitor treatments to make sure your doctor is doing what the federal government deems appropriate and cost effective. The goal is to reduce costs and ‘guide’ your doctor’s decisions.” 9

Ms. McCaughey has read the Stimulus bill as well as a book Daschle wrote on how to change health care in the US. She notes that the new program is modeled after the UK health care system. So, to get an idea of what Obama intends with this new federal agency, I took a look at the UK national health care agency, on which the Obama/Daschle plan is presumably based. The English agency is called “NICE” which stands for “The National Institute for Health and Clinical Excellence.” 10

First, an explanation of how health care works in England:

Healthcare in England is mainly provided by England’s public health service, the National Health Service, that provides healthcare to all UK permanent residents that is free … and paid for from general taxation.… Though the public system dominates healthcare provision in England, private health care and a wide variety of alternative and complementary treatments are available for those willing to pay. 11 (Emphasis supplied).

The English system has a very detailed set of “guidelines” that inform health care professionals and citizens what type of public care they are to get. The guidelines are specific to the particular malady, and are tailored, based on a cost-benefit analysis, to the fitness and age of the patient. Quite remarkably, the English have gotten it down to a formulae whereby they input the degree of your disease, your age, your fitness, the likelihood of complications, and anything else they can think of, and come up a dollar amount that it will cost, per day, to extend your life with whatever treatment is at issue. You really have to read some of these things. Here is one of the few that wasn’t so convoluted that I could understand it:

The results show that radical prostatectomy costs approximately £4400 more than watchful waiting, but that radical prostatectomy produces an average discounted increase in life expectancy of 0.5 years. This is equivalent to an ICER [incremental cost effectiveness ratio] of approximately £9000 per life-year gained. When no post-operative complications were assumed, radical prostatectomy was also associated with approximately 0.5 extra QALYs [quality adjusted life years], with an associated ICER of £7918. However, when treatment related side effects were assumed to occur, as described in the methods section, radical prostatectomy was ‘dominated’ by watchful waiting (the main baseline result). That is, radical prostatectomy was more costly and less effective than watchful waiting. 12

I was looking at the issue of prostate cancer, which is near and dear to my heart, since my dad had it and I am already showing signs of significant prostate enlargement. Here are some excerpts of what NICE says:

In order to identify men who are most suitable for prostate biopsy, there is a need to identify a group at high risk, not just of prostate cancer, but of significant prostate cancer. (Emphasis in original). 13

The question is, then, what level of cancer must you have to justify the first step in obtaining curative treatment? Well, the next sentence is revealing:

Several large studies have analysed the clinical characteristics associated with the finding of higher grade (usually defined as Gleason score ≥7) prostate cancer on biopsy. 14

Here is the NICE table:
Risk, PSA, Gleason
Low risk < 10 ng/ml and ≤ 6
Intermediate risk 10–20 ng/ml or 7
High risk > 20 ng/ml or 8-10

According to NICE, a PSA of 20 and a Gleason score of 7 indicate only an “intermediate risk.”

Compare that with how American doctors view the scores:

A … Gleason score of 10 is very bad. … Here’s how the scores break down:
Scores from 2 to 4 are very low on the cancer aggression scale.
Scores from 5 to 6 are mildly aggressive.
A score of 7 indicates that the cancer is moderately aggressive. Scores from 8 to 10 indicate that the cancer is highly aggressive. 15

And note how one of the nation’s top expert views the issues:

Dr. [William J.]Catalona, … a professor of urology at Northwestern University’s Feinberg School of Medicine … developed the PSA test as a screening test for prostate cancer, … . PSA is a protein, in this case produced by the prostate gland… [W]hen something is going wrong in the prostate, PSA leaks into the bloodstream.

The generally accepted cutoff for recommending a biopsy was initially a PSA of 4.0 or higher. … Dr. Catalona has urged an even lower PSA indicator. … He recommends biopsies … be conducted when the PSA level reaches 2.5. 16

Clearly, there is a significant difference in what American doctors verses English doctors consider deserving of curative treatment. The English system is biased against discovering cancer. The American system seeks to find it, and kill it.

But what do they do once you have finally satisfied English docotrs that the cancer is really serious? Take a look at the treatment options:

Initial Treatment Options

The treatment options for men with localised prostate cancer are:

watchful waiting
active surveillance
radical prostatectomy (open, laparoscopic or robotically assisted laparoscopic)
external beam radiotherapy (EBRT)
brachytherapy (low and high dose rate)
high intensity focused ultrasound (HIFU)
cryotherapy. 17

Anyone see “Cyber Knife” in the treatment options? Three years ago my dad, at age 74, got this state-of-the-art treatment and it totally killed his prostate cancer. Cyber Knife involves shooting a beam into the body from a couple of different directions and, where the beams meet, or some such, the cells die. Elsewhere, the cells in the body are not harmed. This is an expensive machine that, apparently, they don’t offer in the UK. In fact, just this month (February, 2009), the very first Cyber Knife in the UK is being installed at a swanky PRIVATE hospital. 18 No Cyber Knife at all for the masses. Oh, and so you know, my dad was on Medicare and got the treatment of his choice.

Yet, my dad would not have qualified for treatment of any type on the idea that he was likely to die pretty soon anyhow. And, lo, that in fact happened. My dad died last November of the same brain cancer that Ted Kennedy has. Didn’t Ted have VERY EXPENSIVE surgery… even at his age? Anyway, back to the English attitude toward prostate cancer:

Watchful waiting

Watchful waiting involves the conscious decision to avoid treatment unless symptoms of progressive disease develop. Those men who do develop symptoms of progressive disease are usually managed with hormonal therapy. This approach is most often offered to older men, or those with significant co-morbidities [this is a euphemism for “old and likely to die in a few years anyhow”] who are thought unlikely to have significant cancer progression during their likely natural life span. 19

Get that? If you are an older man you get to watch the cancer grow. The idea is, you are likely to die pretty soon anyhow, so the cancer isn’t likely to shorten your life enough to warrant treatment.

Let’s look at the next stage of treatment:

Active surveillance
Whereas traditional watchful waiting in elderly or infirm men aims to avoid any treatment at all for as long as possible and excludes radical treatment options, active surveillance of younger, fitter men tries to target curative treatment on those likely to benefit. Active surveillance enables the risk category to be re-assessed at regular intervals by serial PSA estimations, and trans-rectal ultrasound (TRUS) guided prostate biopsy. 20

Recommendations
Men with low-risk localised prostate cancer who are considered suitable for radical treatment should first be offered active surveillance. Qualifying statement: There is no reliable evidence of the clinical or cost effectiveness of radical treatment in this group of men. 21

Ok, so now, even if you would otherwise be qualified for medical treatment, you should first be offered active surveillance. That is, you will not get medical treatment even at this point. Moreover:

The decision to proceed from an active surveillance regimen to radical treatment should be made in the light of the individual man’s personal preferences, co-morbidities and life expectancy … 22

So, if you are a fit young man you get treatment. Otherwise, it’s just too expensive. Too bad, so sad; sucks to be you.

Summary

Where does this leave us?

Few people would argue that health care in the US needs to be reformed. It may be that we need to limit treatment based on some measure of cost-benefit. We may need to ration care in limited situations. We may even need to alter our personal, and national, priorities. But it goes without saying that we must have an open and detailed discussion of the issues.

Instead, we have a President who is using an economic “crisis,” some would say created by housing policies his party foisted on the free market, to sneak far-reaching legislation into a Stimulus bill that is being rammed down our collective throats.

When President Obama promised change, he wasn’t kidding.

He was threatening.

Cameron Reddy

Footnotes:

1 Stimulus Bill, Page 441.

2 Id. at 441.

3 Executive Order 13335.

4 Stimulus Bill. at 441.

5 http://www.thefreedictionary.com/federal+office

6 HR1 2009 Stimulus Bill at 173-175.

7 Wikipedia article on Betsy McCaughey, Commentary on 2009 Stimulus Bill.

8 Ms. McCaughey is an expert on the subject of health care public policy. Among other accolades, she won the H.L. Mencken Award and the National Magazine Award for the best article in the nation on public policy for her 1994 analysis of the Clinton health plan. Not surprisingly, albeit with perhaps some justification, she drew criticism from various left-leaning publications.

9 Bloomberg.com article

10 http://www.nice.org.uk/aboutnice/about_nice.jsp

11 http://en.wikipedia.org/wiki/Healthcare_in_England

12 NICE.pdf, Page 78

13 Id. at 13.

14 Id. at 13

15 dummies.com/how-to/content/making-the-grade-with-the-gleason-score.html

16 http://www.scienceblog.com/community/older/2004/6/
20045696.shtml

17 NICE pdf at 24.

18 HCA hospital group.

19 NICE pdf at 24.

20 Id. at 25.

21 Id. at 25.

22 Id. at 25.