Hidden Health Care Overhaul in Stimulus Bill
by Mary Budinger
Senator Tom Daschle lost his chance to be the Secretary of Health, but his handiwork is evident in the new federal Stimulus Bill. The stimulus package is more than a $787 billion attempt to create jobs. Buried in its 1000 or so pages is a still murky revamping of the American healthcare system.
One part of the health care component that is generating considerable concern is the creation of a new council of 15 federal employees to coordinate $1.1 billion in comparative research to determine the effectiveness of drugs, medical devices, surgery and other treatments.
Betsy McCaughey, former lieutenant governor of New York and an adjunct senior fellow at the Hudson Institute, thoroughly read the House version of the bill and sounded a warning in a February 9 editorial in Bloomberg News.
"Tragically, no one from either party is objecting to the health provisions slipped in without discussion," McCaughey wrote. "Senators should read these provisions and vote against them because they are dangerous to your health. The bill's health rules will affect 'every individual in the United States' (pages 445, 454, 479 - page numbers refer to H.R. 1 EH, pdf version). Your medical treatments will be tracked electronically by a federal system."
McCaughey points out the bill goes further. "One new bureaucracy, the National Coordinator of Health Information Technology, will 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 (pages 442, 446). These provisions in the stimulus bill are virtually identical to what Daschle prescribed in his 2008 book, Critical: What We Can Do About the Health-Care Crisis. According to Daschle, doctors have to give up autonomy and 'learn to operate less like solo practitioners.'"
There's nothing particularly new about comparative effectiveness research - the National Institutes of Health, along with the Agency for Healthcare Research and Quality, have been doing it for years, with a budget last year of about $335 million. But the goal was usually to establish if a particular treatment was safe and effective, not if it was better than the alternatives.
"The stimulus bill will affect every part of health care, from medical and nursing education, to how patients are treated and how much hospitals get paid," McCaughey wrote.
McCaughey is not alone. Words of caution also came from William Winkenwerder, Jr., M.D., MBA, who served as Assistant Secretary of Defense for Health Affairs in the U.S. Department of Defense 2001 - 2007, and Grace-Marie Turner, president of the Galen Institute, a think tank specializing in health reform, and a previous member of the federal Medicaid Commission. They wrote for the National Review that, "This is the biggest land grab in the health sector ever attempted by the federal government, and it would be a major step toward thrusting full responsibility for health-care financing onto the American taxpayer-today and for decades to come."
And the 15-member federal health board? "Composed entirely of federal employees appointed by the president, charged with running 'comparative effectiveness' research to assess which drugs and other medical treatments are most effective," they explained. "The board's decisions would determine what medical treatments the federal government would or would not pay for. The treatments some patients desperately need might not be on the list. House Appropriations Chairman David Obey (D., Wis.) explained that drugs and treatments 'that are found to be less effective and in some cases, more expensive, will no longer be prescribed.'"
Opposing Views
Linda Bergthold wrote in the Huffington Post that McCaughey was huffing about a lot of nothing. "Does anyone care about the facts?" Bergthold asks. "This so-called Federal Health IT Coordinator was actually established by President Bush in 2004. It was a Republican idea. And the money in the Stimulus Bill expands that activity to help hospitals and doctors around the country turn their paper records into electronic ones."
Bergthold argues that the money for comparative research, "is meant to stimulate more information about what works and make that information available to patients and doctors. In fact, in a press statement from the Senate Finance committee, it is made completely clear that this information may NOT be used by Medicare to make coverage decisions."
Dr. Elliott S. Fisher of Dartmouth Medical School said the Federal Council would attempt to answer whether it is better to treat severe neck pain with surgery or a combination of physical therapy, exercise and medications. What is the best combination of prescription drugs and counseling for mild depression? How do drugs and "watchful waiting" compare with surgery as a treatment for leg pain that results from blockage of the arteries in the lower legs?
In a report filed with the final version of the bill, negotiators said they did not intend for the research money to be used to "mandate coverage, reimbursement or other policies for any public or private payer."
Steven Pearlstein, business columnist for the Washington Post, described McCaughey's commentary as a right-wing brushfire, "a work of political arson by the country's drugmakers and medical device makers, which have the most to lose if there is solid research showing that some of their most expensive and high-margin products aren't really better than the low-priced spread. The flames were also fanned by 'disease groups' like Easter Seals and the American Cancer Society, which fear that any attempt to determine what works best will inevitably lead to a one-size-fits-all approach to treating people with serious chronic conditions."
Andrew Witty, the chief executive of the pharmaceutical company GlaxoSmithKline, said European officials often weighed the costs versus clinical benefits of new drugs and got mixed results. "Other countries have fallen in love with the concept [of comparative effectiveness], then spent years figuring out how on earth to make it work," Witty said.
Health Care Hidden in an Economic Bill
As Bergthold points out, the health care portion of the stimulus bill has been bouncing around since at least 2004. A year ago, Senator Daschle wrote that the next president should act quickly before critics mount an opposition. "If that means attaching a health-care plan to the federal budget, so be it," he said. "The issue is too important to be stalled by Senate protocol."
Some lawmakers expressed concern about the underhanded appearance. "We are not going to let the federal government monitor what doctors do," Sen. Arlen Specter said the day after McCaughey's editorial. Specter was one of only three Republicans to support the Democrats' stimulus/spending bill.
"If Bloomberg News has pointed out a potential problem…there will be clarification to avoid having the government meddle in what doctors do," Specter said.
Specter said the provision for $19 billion on electronic health records was intended to "provide technology" - to computerize the health records of all Americans. He said the government should not be in the business of making decisions on patients' treatment.
Specter noted that Congress never held hearings on the bill, and that has created problems. "This is one of a number of provisions that has popped up that we have to revise and be very careful about." Specter said he protested the rush to judgment, but "the only answer we get is that the situation is so dire, such an emergency, we have to act."
Stimulus Priority on Health Care
In a public opinion survey conducted in January by the Harvard School of Public Health and the Kaiser Family Foundation, helping the newly unemployed pay for health insurance ranked second only to helping businesses keep or create jobs as the top priorities for President Obama and Congress.
"It was higher than tax breaks for the middle class and higher than helping people pay their mortgages so they can stay in their homes," says Robert Blendon, professor of health policy and political analysis at the Harvard School of Public Health. "And it wasn't listed as a healthcare issue. It was listed as an economic stimulus issue: Helping people who just lost their jobs pay their health insurance is something that people can really see as instant relief."
Congress also approved spending about $17 billion in higher government health insurance payments for doctors and hospitals, beginning in 2011 when they adopt electronic health records. The bill also calls for $500 million on incentives for physicians, dentists and nurses to practice in communities where there is limited access to health care; and about $300 million to provide additional vaccinations.
Doctors See Danger
Many doctors feel the stimulus bill has a hidden agenda to eliminate alternative medical practitioners by encouraging conformity in medical practice.
"Congressional Democrats are using the cover of an economic crisis to advance an agenda that will destroy the doctor-patient relationship and set us on a course for government-administered health care," said Representative Tom Price (R-Georgia), a doctor.
"Nationalized health is upon us, hidden in the fine print with limitations on doctors' choices about treating patients," another doctor said privately. "'Standard care' decided by the government, not your doctor, is what you will get."
Larry Trivieri, Jr., co-author of The Alkaline-Acid Food Guide, said: "One-size fits all, cookie-cutter medicine is already the dominant health care approach of far too many conventional and alternative physicians today, and we already know how poor the outcomes of such an approach to medicine are. The stimulus bill has the pharmaceutical industry's handwriting all over it. Only drug-based medicine can thrive under such rigid measures of medicine. And only drug-based medicine can survive the stringent cookie-cutter measures that will be imposed on doctors and hospitals after this bill passes."
As Winkenwerder and Turner pointed out, "The U.S. already spends $2.2 trillion a year on health care, and it is widely acknowledged that we are not getting anything close to our money's worth. Can we invest an additional $160 billion wisely? Highly unlikely."
The devil is in the details, as the saying goes. Because this bill was so large, and rushed through without time for debate, most people really will not know what's coming until it is upon them. Most people are in the same boat as this person who responded to one of the on-line stories about the stimulus: "As a chronically ill person, I am incredibly curious to see how this all is applied to every day health care and health care professional interactions."
The only thing that seems clear in wake of the bill's passage is that it represents a sharp turn toward greater government control over our health sector.
