– Bernd Debusmann is a Reuters columnist. The opinions expressed are his own. –

Four days before Barack Obama was sworn into office, a prominent radio talk show host, Rush Limbaugh, told his conservative listeners that a major American publication had asked him to write 400 words on his hopes for the Obama presidency.

“I…don’t need 400 words,” he said, “I need four: I hope he fails.”

The remark set the tone for a steady stream of unbridled and often bizarre criticism from Limbaugh and like-minded radio and TV commentators, several of them working for Fox News, the network owned by media mogul Rupert Murdoch. Obama responded four days after his inauguration, telling a group of Republican congressmen they needed to break away from a mindset of confrontation.

“You can’t just listen to Rush Limbaugh and get things done.”

What followed should have helped the new administration to reflect on the wisdom of singling out a media critic. But it didn’t. Limbaugh promptly portrayed himself as a man of such pivotal importance that the president of the world’s only superpower needed to pay personal attention to his tartly-worded opinion.

The controversy over his ill wishes for the president caused, as he put, his ratings to go “through the roof,” a reassuring development for a man who makes $38 million a year under an eight-year contract that runs through 2016. The score of that early skirmish: Limbaugh 1, Obama 0.

The White House is now engaged (as in war, not diplomacy) with an even bigger target, Fox News, to the evident delight of Murdoch. “There were some strong remarks coming out of the White House about one or two of the commentators on Fox News,” he told the annual shareholders’ meeting  of News Corp, the media conglomerate that includes Fox. “And all I can tell you is that it has tremendously increased their ratings.”

His cheerful observation came a few days after the administration switched from occasional counter-attacks to full-scale offensive. Anita Dunn, the White House Communications director, fired the first rocket in mid-October by saying Fox News was not a legitimate news organisation but operated as a research and communications arm of the Republican Party.

The president himself stayed out of the fray this time but two of his closest aides, Senior Advisor David Axelrod and Chief of Staff Rahm Emanuel followed up with similar comments on television news shows. Axelrod went as far as to urge other news organisations not to treat Fox News as a legitimate news outfit. Fox denies its news coverage is slanted and says critics fail to understand the difference between reporters and commentators.

SHOCK VALUE AND SHOW BUSINESS
Past performance is no guarantee of future results but it is probably a safe bet that the controversy will be good for the Fox bottom line - and that the commentators with the most provocative attacks on Obama will benefit most, a pattern reflected by the network’s third quarter results.

They showed Fox News as the dominant cable news organisation. It drew an average 2.25 million prime time viewers (a 2 percent increase over the previous year) - more than twice the combined number of its nearest competitors, CNN and MSNBC, both of which suffered considerable audience declines.

The shows by Fox’s top conservative commentators all showed steep increases, but none more than Glenn Beck (up almost 90 percent), who said of Obama on a Fox show in July: “This president has exposed himself as a guy, over and over again, who has a deep-seated hatred for white people and white culture.”

Commentators aiming for shock value are not in the business of context, such as pointing out, for example, that Obama’s mother was white and that he had close and cordial relations with his white grandparents. Obama was visibly shaken when his white grandmother, Madelyn Dunham died, a day before he was elected president.

Beck’s “hatred for white people” remark prompted several advertisers to abandon his show but that didn’t hurt the bottom line. A Fox spokeswoman said at the time that offended advertisers had shifted to other Fox programmes so there was no revenue lost.

Which raises the question why Fox News, which effectively functions as the voice of the opposition, has been more of a commercial success than its competitors which feature liberal, pro-Obama commentators and give a platform to people who want the president to succeed?

After all, he won the elections with the votes of Americans who bought into his reform agenda. And according to a Washington Post/ABC poll to mark his ninth month into the presidency, his job approval rating stands at 57 percent and only 20 percent of the country now consider themselves Republican, the lowest percentage in 26 years.

Even on the most hotly disputed aspect of Obama’s health care plan, the public option seen as socialism by conservative commentators, a majority of  Americans are coming out in support of the president, according to that poll.

So why is the White House acting as if right-wing critics pose a mortal danger? Thin-skinned sensitivity to criticism? John Batchelor, a conservative radio show host, has a different suggestion: ignorance.

“The White House war on Fox,” he wrote on the website The Daily Beast, “shows its ignorance of the network’s true purpose: show business. And Team Obama is giving Murdoch just what he wants.”

– David Magnus, Phd, is the director of the Stanford Center for Biomedical Ethics. The views expressed are his own. –

The public discussion of healthcare reform has been full of so many lies and myths that it is less a policy debate than bad theater.

Critics of reform (conservatives hoping to score political points and oppose Obama on anything; free market ideologues; those with threatened financial interests) have stooped to absurdity in their public pronouncements. One publication declared that severely disabled physicist Stephen Hawking would never get life saving medicine in a national health system, ignoring that Hawking is British—virtually all of his life saving treatments were done through their National Health Service.

As debate over reforming health care continues, these are some of the key myths that get in the way of truly meaningful discussion.

Myth #1—We have the best health care in the world

This is probably true for some Americans. But on the whole our system is among the poorest of all developed nations. We spend far more per capita than any of our peers on healthcare, yet health outcomes measures are no better in aggregate. The World Health Organization ranking of health systems rated 36 other countries as having better health systems despite spending far less. The U.S. was right behind Costa Rica (and only two spots ahead of Cuba).

But the reality of the failure of our health system is best seen by the thousands of people being turned away in Los Angeles last week at the massive free clinic set up by the Remote Area Medical Foundation (see Reuters story). When the country spending the most money can not meet the basic medical needs of so many of its citizens, it does not have a good (or just) health system, much less the best system.

Myth #2—Health reform will lead to less personal freedom

There is nothing in any of the proposals that requires anyone to give up her existing health plan. In fact, Medicare proves that public-private partnerships can result in individuals choosing their own plans and their own physicians. Opponents of reform have argued that any government involvement means loss of freedom. This ignores the reality that insurance companies, employers, and financial limitations are already curtailing freedom for many individuals. When co-payments are too high, or someone has no insurance and health care means going bankrupt, those are real losses of freedom. It is ironic that unwavering faith in the free-market (and contempt for any government role) is being expressed at the same time the country is recovering from an economic meltdown caused by too much greed and too little government oversight.

None of the proposed plans involve socializing medicine, creating a single payer system, or government run or owned hospitals. They merely acknowledge the reality that a morally defensible health care system will only come about with some government involvement.

Myth #3—Health reform will control costs by depriving patients of needed medical treatments

There is absolutely nothing in any of the reform measures that suggests or requires that needed medical treatments will not be available. In contrast, within our existing system, those without insurance or “under-insured” patients who can not afford rising out of pocket payments are denied needed medical treatments on a routine basis. Reform makes it more likely that patients will receive needed medical treatments (not less likely).

Myth #4—Health Reform will deny older Americans medical treatments at the end of life

The lies about “death panels” that Palin, Gingrich, and others have been spewing have led the Senate to withdraw one element of the House legislation that would have both reduced costs and increased patient freedom. This is the proposal that would have allowed payment to primary care physicians who spend time with their patients talking about the patient’s wishes with regard to end-of-life decision-making. Right now, 25 percent of Medicare is spent on the last two months of life. Families in these contexts often face difficult decisions with no idea of what a patient’s wishes are. In those settings, we typically default to providing more aggressive measures, even if it increases suffering and may be at odds with a patient’s wishes. Encouraging patients to make choices ahead of time–whether for more aggressive measures or for a greater focus on comfort at the end of life– promotes freedom and has the potential to reduce costs (since 80 percent of people prefer less aggressive care).

This is the precisely the role that government should be playing—creating incentives for good medicine that promotes patient autonomy—and to counter existing incentives which all too often lead to less choice, more suffering, and increased costs. When Palin, Gingrich and others portray talking about our wishes with our doctors as “death panels”, when they attack scholars’ work out of context, when they misrepresent what is in proposed legislation, they undermine any hope of rational dialogue about the ethical challenges presented by health care and the very important and very real challenges and trade-offs that should be the subject of debate.

Peter J. Pitts is president of the Center for Medicine in the Public Interest and a former FDA associate commissioner. The views expressed are his own.

In SiCKO, Michael Moore portrayed the British National Health Service and the Canadian health system as particular exemplars of excellence. He backed it up with a lot of statistics, but statistics, as the saying goes, are like a bathing suit. What they show you is interesting, but what they conceal is essential.

And what SiCKO concealed was that systems such as those in the United Kingdom and Canada are cost-based rather than patient-centric models. Facts, no matter how inconvenient to one’s argument, must not be ignored.

Citizens of countries with government-run health care systems experience long wait times, a lack of access to certain treatments and, in many instances, substandard medical care. For example:

• The five-year survival rate for early diagnosed breast cancer patients in England is just 78 percent, compared to 98 percent in the U.S.

• A typical Canadian seeking surgical or other therapeutic treatment had to wait 18.3 weeks in 2007, an all-time high, according to The Fraser Institute.

• The average wait time for bypass surgery in New York is 17 days compared to 72 days in the Netherlands and 59 days in Sweden.

• More than half of Canadian adults (56 percent) sought routine or ongoing care in 2005. Of these, one in six said they have trouble getting routine care.

• Eighty-five percent of doctors in Canada agree private insurance for health services already covered under Medicare would result in shorter wait times.

• Approximately 875,000 Canadians are on waiting lists for medical treatment.

“Congress has an important role to play in healthcare reform” said United States Representative John Shadegg, (R-Arizona), who has introduced healthcare legislation in support of free-market competition. “We can help patient in this country, not by setting up a massive new government bureaucracy, but by empowering individuals to make the best choices for themselves and their families.”

If we’re going to look to other healthcare models for solutions, we must uncover and study their problems. Health care is too important to allow reform by sound bite. “Drugs from Canada” is as much a false promise as “free” healthcare.

Last autumn, my organization the Center for Medicine in the Public Interest interviewed people on the streets of New York City and asked them if they’d prefer “government” healthcare or “universal” healthcare. They overwhelmingly chose “universal” healthcare. But when we asked them to explain the difference between the two, they generally just shrugged their shoulders.

And when we asked them how much more in taxes they’d be willing to pay to support universal healthcare, they shook their heads and said, “No, we want it to be free, like in Europe and Canada.” Such are the fallacies that political rhetoric hath wrought.

Equally as prevalent is the notion of “free” or “low cost” drugs “like in Canada and Europe.” And here too we need to be honest and examine the other side of the coin — that of cost-savings for the payer (often in the guise of healthcare technology assessment programs such as Britain’s National Institute for Health and Clinical Excellence) versus care denied for the patient. What is overlooked is that price controls equals choice controls.

Our national conversation about health care has to go beyond vague concepts of reform and convenient political rhetoric. We must all be part of the solution and suspicious about false choices.

– Stephen M. Davidson, a Boston University School of Management professor, is author of the forthcoming book, “In Urgent Need of Reform: Saving The U.S. Healthcare System.” The views expressed are his own. —

Polls suggest the president is losing some popular support for his health care reform efforts apparently because people worry about some of the possible secondary effects. They fear that quality of care would decline, their out-of-pocket costs and taxes would increase, and they would not be able to choose their own doctor. The fact that there is little reason for these worries is beside the point.

Ordinarily, when a problem arises, we try to figure out what the cause is and fix it.  With legislation, especially something as complex as healthcare, we don’t do that. Instead, we impose constraints that are unrelated to the diagnosis. In this case, Congress is trying to fix the problems using private insurers, without raising taxes, and keeping a limited role for government. So, leaders try to fashion a bill that accomplishes at least the main goals of reform – reducing the numbers of uninsured and containing costs – are at a considerable disadvantage. Partly as a result, it is much harder to persuade the American people that the complicated plans they come up with will do the job without harming them.

The fact is that much simpler solutions are available.  For example, require that everyone contribute an income-related amount (that is, more for higher-income people) to a dedicated federal health insurance fund (HIF), which would be used to pay insurers and health plans. And then issue vouchers which entitle everyone to choose a health plan or insurance policy.

The contribution can be called a tax, which makes it a non-starter, even though it would probably mean that almost everyone would pay less than they do now. It would substitute for the premiums they now pay as well as for most of the taxes that go to health-related activities.  (If Medicaid were folded in, the savings would be even greater; Medicare is so popular with an important constituency that it would be harder to include it in a new plan.) The amounts paid could be based on a person’s income (like our progressive income tax), which means those with pre-existing conditions would not face unaffordable premiums.

Using our vouchers, we would choose our own insurance policies from private insurers.  Not only would the insurance cover the services we need, but instead of basing our choices on what we can afford (which might not cover what we need, which is the case for millions of Americans today), they would be based on the providers available and the quality of the insurer’s service. The insurers, in turn, could be paid risk-adjusted amounts from the HIF, which would protect them against the possibility that large numbers of people with pre-existing conditions and other risk factors would choose them.

The federal agency that administers the HIF would have only a few jobs to do:  estimate the total needed for the next year and set contribution rates to produce a large enough fund; certify insurers as capable of performing the necessary insurance functions and inform the public about those firms; and set the risk-adjusted rates to be paid to the insurers.

Insurers would negotiate compensation arrangements with providers for the patients who choose them.  Risk-adjusted payments would protect them to a considerable extent, but some might decide to transform themselves into prepaid group practices like Group Health of Puget Sound or find other ways to assure quality care at reasonable cost.  Plenty of models are available for them to choose.

This approach sounds radical.  But if you think about it – without the Congressionally imposed constraints – it is really quite simple.  The federal government already knows how to set and collect progressive taxes, private insurers and providers already negotiate with one another, and having a voucher assures coverage and simplifies the insurance choice process.  Most importantly, it would actually accomplish the two main goals of reform: providing insurance to everyone and containing costs.

– Nancy Duff Campbell is a founder and co-president of the National Women’s Law Center, one of the nation’s pre-eminent women’s rights organizations. A recognized expert on women’s law and public policy issues, for over thirty-five years Ms. Campbell has participated in the development and implementation of key legislative initiatives and litigation protecting women’s rights, with a particular emphasis on issues affecting low income women and their families. The views expressed are her own. —

Insurance companies and others who profit from our broken health care system are mobilizing to defeat comprehensive reform by using misinformation and scare tactics. A prime example is the allegation that healthcare legislation – specifically the plan being considered by the House of Representatives – will hurt small businesses.

The fact is that small business owners, especially women, are already hurting under our current healthcare system. Leah Daniels, 29, is the owner of Hill’s Kitchen – a gourmet kitchenware store that opened last May not far from the U.S. Capitol. Daniels can’t afford to offer health insurance to her three employees. She purchased her own bare-bones plan on the individual market for protection “in case I get hit by a car,” but not much else. It costs her just under $200 a month and doesn’t cover such services as routine doctor’s visits or maternity care. Daniels, who often works 7 days a week, says that she is constantly worried about getting sick.

Daniels’ problems are, unfortunately, all too typical. A new report by the Council of Economic Advisers (CEA) found that small businesses pay up to 18 percent more than large firms for the same health insurance policy. These higher costs mean that small businesses are considerably less likely than larger businesses to provide health insurance to their employees, and those that do tend to have less comprehensive plans. And Census data show that women-owned businesses are generally smaller than male-owned businesses.

Small business owners and employees who don’t get coverage at work or through a spouse’s plan may shop for insurance individually. But if they are women – and small businesses that don’t offer health coverage tend to have large proportions of female workers – they are likely to face discrimination in the individual health insurance market. A study by the National Women’s Law Center found that insurance companies routinely charge women higher rates than men for individual policies and offer policies that exclude health needs specific to women, such as maternity care.

Women who own a small business know that the current health care system is failing them. At a meeting of women small business owners in May, Daniels says, “We went around the room and everyone either had health insurance through their spouse or didn’t have coverage at all. Women talked about being afraid to go to the doctor because they didn’t want to find out that they might be sick. It was really striking.”

The healthcare reform plans that have begun moving through Congress would help make it possible for small business owners to offer comprehensive, affordable health insurance. The House plan would make insurance more affordable by prohibiting insurance companies from discriminating on the basis of health status or gender and by allowing small businesses to purchase coverage through a new Health Insurance Exchange. The Exchange would reduce administrative costs and offer a choice of plans meeting minimum benefit standards. New tax credits would be available to help some small businesses pay for employee health coverage; the credit would be worth 50 percent of the cost of qualified health coverage expenses for businesses with 10 or fewer employees and average wages of $20,000 or less. It would gradually be reduced until firms reached 25 or more employees or average wages of $40,000 or more.

If some employers still can’t provide coverage, their employees could purchase insurance directly from the Exchange. Sliding scale subsidies would help make it affordable, and they couldn’t be turned down because of pre-existing conditions or charged more because of their gender or health history. Larger employers who fail to offer health care coverage would be required to pay an additional payroll tax, but under the plan being developed by the House, businesses below a certain size would be exempt. One version would exempt businesses with payrolls of $500,000 or less. Another would set the exemption at $250,000 – but even at this level, 76 percent of all firms would be exempt.

Opponents of healthcare reform have claimed that small businesses would be hurt by another provision: a graduated surcharge on the very wealthy to help finance health care reform. But the surcharge would only apply to households with adjusted gross income above $350,000 ($280,000 for an individual). As a result, only the wealthiest 1.2 percent of taxpayers – and only 4 to 5 percent of all tax payers with business income – would be subject to the surcharge. Women-owned businesses are especially unlikely to be affected by the surcharge. According to the latest Census data, 96.3 percent of women-owned businesses, compared to 88.9 percent of male-owned businesses, had total receipts below $500,000 – meaning that profits would be well below that level.

Those who claim that healthcare reform will hurt small businesses should re-examine their facts – and the rest of us should examine who they’re really speaking for. We can’t afford to wait any longer for meaningful reform that will bring a guarantee of quality, affordable comprehensive health care for us all.

Reuters.com asked members of our expert panel on healthcare reform what role, if any, nonprofit cooperatives should play in healthcare reform policy? Here are their responses:
(Updated at 14:35 ET on July 30 to include Ted Okon’s view.)

Wendell Potter is the senior fellow on healthcare for the Center for Media and Democracy in Madison, Wisconsin. The views expressed are his own.

The idea of nonprofit cooperatives being able to compete effectively with the cartel of large for-profit insurers that dominate the market today is so naive one has to wonder if the legislative language proposing their creation was written by insurance company lobbyists.

The proposal, sadly, reflects a shocking lack of understanding in Congress of how the health insurance industry now operates in the United States. Over the past 15 years, seven for-profit health insurers have become so large that one of every three Americans is enrolled in a plan owned and operated by those seven insurers. The consolidation in the industry has also resulted in 94 percent of insurance markets in America being controlled by a handful of big insurers, often just one or two in many of the country’s biggest metropolitan areas. This means that other insurers cannot enter the market and expect to be competitive.

If large, profitable insurers cannot enter markets dominated by competitors, cooperatives, starting from scratch, wouldn’t have a remote chance of succeeding. Creating co-ops instead of a national public insurance option that actually could compete with the big insurers would be a gift to the industry.

Peter Pitts is president of the Center for Medicine in the Public Interest and a former FDA associate commissioner. The views expressed are his own.

Leading Democrats on the Senate Finance Committee have expressed cautious optimism that they’ll be able to attract bipartisan support for their reform effort by substituting “nonprofit health cooperatives” for the highly controversial public option. The federal government would provide states with the seed money — some $6 billion — to set up state-based or regional co-ops.

But don’t be fooled — a nonprofit health cooperative is little more than the public plan by another name. Both would be government-funded. Both could offer policies in multiple states, outside the purview of state insurance regulators. And both would sound the death knell of private insurance by tilting the playing field irrevocably in the government’s favor.

After all, not only would private insurers remain governed by unique and often burdensome regulations in each of the states. They’d also have to compete against government-funded co-ops that would have the implicit financial backing of the federal government — and thus could charge artificially low rates without risk of insolvency.

If they have any hope of preserving individual choice in health care, lawmakers should refuse to cooperate with these cooperatives.

Dr. Steffie Woolhandler and Dr. David Himmelstein are both associate professors of medicine at Harvard Medical School and primary care doctors at Cambridge Hospital. They co-founded Physicians for a National Health Program. The views expressed are their own.

The proposed cooperatives would add nothing useful to the healthcare landscape. Stripped of the resources that government would bring to the table, they would be under-resourced competitors sure to be swamped by powerful private insurers. The cooperatives under discussion in Washington would be small scale insurers, whose small enrollment would guarantee high administrative costs because the costs of computers, claims processing offices, utilization reviewers etc. would be spread over a small number of patients. And they would lack the resources to effectively compete by marketing to attract healthy, profitable patients and avoid the sick, unprofitable ones.

Ted A. Okon is executive director of Community Oncology Alliance. The views expressed are his own.

Local and regional nonprofit health insurance cooperatives have been offered as a solution to the near monopoly power of private insurance companies. Unfortunately, history and market economics stand against cooperatives as an effective solution. First, we forget that we have already been down the road of having nonprofit entities control the healthcare market and have failed. Second, our country does not run by having nonprofit entities produce effective, cost-efficient products. Nonprofits are effective as advocates for causes but not as producers of products. The cost and expertise needed to create a cooperative that could compete with well-entrenched competitors would be prohibitive.

A better solution to the problem is a nonprofit entity running a tight insurance exchange that lists all insurance products and options in an easy-to-understand and transparent manner. Concurrently, local and regional markets need to be investigated to break monopolies where they exist and allow more competition by lowering barriers to entry.

– James Pethokoukis is a Reuters columnist. The views expressed are his own —

Time for a political reality check. Government-run public health insurance that competes with private plans — a Democratic dream since President Truman suggested it in 1945 — may not be dead for now on Capitol Hill, but its vital signs are awfully faint.

Of course, many proponents are hoping to use the congressional August recess to rally the grassroots and the netroots for one final push come September. And maybe that will work.

But it’s more likely that Democratic leaders in Washington will use the break to tell the outside-the-Beltway crowd the cold truth: If they want something that can be legitimately called “healthcare reform” to pass in 2009, they need to quit wasting time, energy and money on the fading dream of a public plan and instead work to get other key elements passed.

And what might those elements be?

Analyst Daniel Clifton of Strategas Research makes an educated guess. He thinks President Obama may get the chance to sign an $800 billion (over 10 years) bill that would contain features such an individual mandate to buy health insurance, subsidies up to 300 percent of the poverty limit to purchase a regulated plan through a health insurance “exchange”, and an expansion of Medicaid.
Obama might even get his commission that would try to determine what Medicare pays doctors and hospitals — now that the Congressional Budget Office has determined it would pretty much be powerless.

As one lobbyist put it: “I would see this as mostly a symbolic victory (for Republicans), as the Dems can get most of what they want without calling it a public option. Frankly. it’s pretty close to the Massachusetts model.”

Ah yes, the Massachusetts model. The state passed sweeping reform in 2006 under Governor Mitt Romney. What would a similar approach mean for America?

Well, there would be a lot fewer uninsured people. Massachusetts has halved the number of people without health insurance, with just 2.6 percent not currently covered.

But the reform has been far less successful bringing down costs. For starters, original cost estimates for Commonwealth Care projected the program would cost $400 million in 2008 and $725 million in 2009. The actual numbers were $628 million in 2008 and $869 billion for this year.

Moreover, health insurance premium costs continue to rise at a rapid clip of 9.4 percent a year, compared with 7.7 percent for the United States on average. As the Urban Institute found: “Health spending in Massachusetts is higher than the United States on average and is growing at a faster rate. Furthermore, health insurance premiums are growing even faster than health care costs in the state.”

So America might find itself in 2012 with lots more people covered, but in an ever more expensive system. And President Obama might find himself doing what Romney’s Democratic successor, Governor Deval Patrick, is doing: cutting back the subsidies that allow poorer residents to buy insurance.
The state is also considering moving away from from fee-for-service medicine, where doctors are incentivized to perform lots of pricey procedures rather than focusing on results.

But Obama and Democrats might also make this argument: We expanded coverage and now it’s time to finish the job by getting costs under control. And the only way of doing that is … a public insurance option!

Indeed, the Urban Institute makes the same argument that Team Obama surely would: that the presence of a national plan would force insurers to compete with a plan with strong bargaining power and, as an arm of government, a powerful financial interest in containing costs.

What’s happening in Washington isn’t the end of healthcare reform, it’s  merely the end of the beginning.

– Peter Pitts is president of the Center for Medicine in the Public Interest and a former FDA Associate Commissioner. The views expressed are his own. –

As part of its healthcare reform bills, Congress is calling for a more aggressive use of comparative effectiveness research (CER). What does this mean? Is comparative effectiveness the same thing as cost effectiveness?

No. There’s a big difference.

Cost effectiveness research is what The United Kingdom’s National Institute for Health and Clinical Excellence (NICE) does. NICE uses a measure known as a Quality Adjusted Life Year (QALY) to assess whether or not a treatment is cost-effective or not. If providing an additional year of life costs more than $50,000 — the average price of a fully-loaded Land Rover — NICE won’t recommend that treatment.

For example, NICE’s preliminary decision was that four new kidney cancer drugs — Torisel, Avastin, Nexavar, and Sutent — should not be reimbursed by the National Health Service (NHS) because, despite clinical evidence that these drugs can actually help, they weren’t “cost effective.”

Currently, the only available treatment for metastatic renal cell cancer is immunotherapy. This halts the disease’s progress for just four months on average. But if a person isn’t a candidate for immunotherapy, or the treatment doesn’t work, that’s it. They have no other treatment options.

NICE agreed that patients tended to live longer when they were given these drugs. But when they put the data from the trials into their QALY-driven computer models, they found that the drugs cost about £20,000 to £35,000 ($39,000 to $68,000) per patient each year. NICE deemed this too pricey, and didn’t recommend that the NHS cover these drugs.

The result is that government saves money and patients receive an expedited death sentence. That’s not hyperbole, that’s the simple truth about cost effectiveness research.

Comparative effectiveness research is different.

It strives to show which medicines are most effective for a given disease. In other words, CER asks whether drug A or drug B is the “more effective” statin. It examines which of a variety of therapies is the “more effective” treatment for depression. Most of the world refers to comparative effectiveness research as Healthcare Technology Assessment.

But CER raises some serious problems. For instance, how do you compare two molecules (or three or more) that perform differently depending on a patient’s personal genetic make-up?

It’s for this reason in particular that CER often leads to a “one-size-fits-all” approach to treatment.

That’s because the concept behind comparative effectiveness research is good, but the tools aren’t.

CER relies heavily on findings from randomized clinical trials. While these trials are essential to demonstrating the safety and efficacy of new medical products, the results are based on large population averages that rarely, if ever, indicate which treatments are “best” for which patients. This is why it is so important for physicians to maintain the ability to supplement study findings with their own expertise and knowledge of their patient in order to make optimal treatment decisions.

Government sponsored studies that conduct head-to-head comparisons of drugs in “real world” clinical settings are a valuable source of information for coverage and reimbursement decisions — if not for making clinical decisions.

Two studies — the Clinical Antipsychotic Trials in Intervention Effectiveness (CATIE) study, and the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) study — are examples of “practice-based” clinical trials, sponsored in part by the National Institutes of Health, to determine whether older, less expensive medicines were as effective in achieving certain clinical outcomes as newer, more expensive ones.

The findings of both CATIE and ALLHAT were highly controversial, but one thing is not: even well-funded CER can be swiftly superseded by trials based on better mechanistic understanding of disease pathways and pharmacogenomics. And, since most comparative effectiveness studies are underpowered, they don’t capture the genetic variations that explain why different patients respond to medicines in different ways.

But it’s important to move beyond criticizing comparative effectiveness in its current form, and instead focus on a policy roadmap for integrating more patient-centric science into comparative effectiveness research.

Much like the U.S. Food and Drug Administration created something called the Critical Path Initiative to apply 21st-century science to the development of personalized medicine, another national goal should be to create a Critical Path Initiative to apply new approaches to data analysis and new clinical insights to promoting patient-centric healthcare.

Why? Because comparative effectiveness research should reflect and measure individual responses to treatments based on a combination of genetic, clinical, and demographic factors. The first steps have been taken. For example, the Department of Health and Human Services has invested in electronic patient records and genomics.

One way to complement this would be to encourage the Centers for Medicare and Medicaid Services to adopt the use of data that takes into account individual patient needs.

We also need to develop proposals that modernize the information used in the evaluation of treatments. Just as the FDA Critical Path Initiative uses genetic variations and biomedical informatics to predict individual responses to treatment, we must establish a science-based process that incorporates personalized medicine into reimbursement decisions.

For instance, the FDA has developed a Critical Path opportunities list that provides 76 concrete examples of how new scientific discoveries in fields such as genomics and proteomics could be used to improve the testing of investigational medical products.

We need to begin the process of developing a similar list of ways new discoveries and tools (such as electronic patient records) can be used to improve CER.

It’s a complicated proposition, but the goal is simple and essential: cost must never be allowed to trump care, and short-term savings must not be allowed to trump medical outcomes. Just as we need new and better tools for drug development, so too do we need them for comparative effectiveness research.

– Dr. Steffie Woolhandler and Dr. David Himmelstein are both associate professors of medicine at Harvard Medical School and primary care doctors at Cambridge Hospital. They co-founded Physicians for a National Health Program. –

Once they’re finished mandating that we all buy private health insurance, Congress can move on to requiring Americans to purchase other defective products. A Ford Pinto in every garage? Lead-painted toys for every child? Melamine-laced chow for every puppy?

Private health insurance doesn’t work. Even middle class families with supposedly good coverage are just one serious illness away from financial ruin. In a study carried out with colleagues from Harvard Law School and Ohio University we found that medical bills and illness contributed to 62 percent of all personal bankruptcies in 2007 – a 50 percent increase since 2001. Strikingly, three quarters of the medically bankrupt had insurance – at least when they first got sick.

In case after case, the insurance families bought in good faith failed them when they needed it most. Some were bankrupted by co-payments, deductibles, and loopholes that allowed their insurer to deny coverage. Others got too sick to work, leaving them unemployed and uninsured.

Now Congress seems poised to fulfill insurance executives’ prayers; make failure to buy their faulty product a federal offense. We’ve seen this brave new world in Massachusetts. Here, beating your wife, communicating a terrorist threat and being uninsured all carry $1000 fines. Our law has halved the state’s already low uninsurance rate – mostly by expanding Medicaid and similar programs at great public expense.

But reform hasn’t made care affordable for middle class families, or for the public treasury. A middle income uninsured 56 year old is now forced to lay out at least $4,800 for a policy with a $2,000 deductible before it pays for any care, and 20 percent co-payments after that. Skimpy, overpriced coverage like this left one in six Massachusetts residents unable to pay their medical bills last year.

Even among the insured, 18 percent skipped care because they couldn’t afford it. Meanwhile, as costs rise for subsidized coverage our state Senate plans to drop 28,000 people from the insurance rolls, and public hospitals and clinics have suffered draconian cuts as funds were diverted to shore up the reform.

Such shrunken coverage for the middle class and the evisceration of institutions that care for the poor prefigure the ugly reality of the president’s plan. Searching for the $150 billion extra he’d need each year just to cover the uninsured, Obama threatens to tax health benefits for those who are currently insured, effectively increasing its price. And he’d drain Medicare and Medicaid funds from safety net hospitals, anticipating a sharp drop in those unable to pay for care – a drop which has largely failed to materialize in Massachusetts.

The President’s other proposed funding streams aren’t objectionable, just illusory: unenforceable pledges from hospitals, insurers and the AMA to slow health inflation – a repeat of the empty promises made when Presidents Nixon and Carter threatened cost controls; and the assumption of windfall savings from computerization and care management, assumptions that the Congressional Budget Office has dismissed as wishful thinking.

A single payer reform could realize about $400 billion in savings annually on health care bureaucracy – enough to cover the uninsured and to provide first dollar coverage for all Americans. But the vast majority of these savings aren’t available unless we go all the way to single payer.

Adding a public insurance plan option – as the president proposes – won’t fix the flaws in Massachusetts-style reform. A public plan might cut private insurers’ profits, which is why the insurers hate it. But insurers’ roughly $10 billion in annual profits is only a sliver of the money squandered on bureaucracy.

The complexity and fragmentation of an insurance system with multiple competing payers breeds this massive waste. In addition to their profits, insurers spend vast amounts on overhead for marketing (to attract healthy, profitable members); demarketing (to avoid the sick); keeping track of their ever-shifting roster of enrollees and collecting their premiums monthly; fighting with hospitals and doctors over bills; and lobbying politicians. And doctors and hospitals spend tens of billions more keeping track of who got every band-aid and aspirin tablet, and fighting with insurers to collect payment.

A single payer plan would eliminate most insurance overhead, as well as these other paperwork expenses. Hospitals could be paid like a fire department, receiving a single monthly check for their entire budget, eliminating most billing. Physicians’ billing could be similarly simplified.

While a public plan option could save on profits, it would forego most of the other $390 billion that single payer could save. Hospitals and doctors would still have to maintain their elaborate billing systems. And overhead for even the most efficient competitive public plan would be far higher than Medicare’s, which automatically enrolls seniors when they turn 65 and disenrolls them only at death, deducts premiums directly from social security checks, and does no marketing.

Moreover, a kinder, gentler public plan would quickly fail in the health care marketplace. Insurers compete by NOT paying for care: by seeking out the healthy and avoiding the sick; by denying payment and shifting costs onto patients; and by lobbying for unfair public subsidies (as under the Medicare HMO program). Competition in health insurance involves a race to the bottom, not the top.

A public plan that abstained from marketing would soon be saddled with the sickest, most expensive patients, whose high costs would drive premiums to uncompetitive levels. Similarly, failure to emulate private insurers’ schemes that shift costs to patients and other payers would be a crippling competitive disadvantage. To compete effectively, a public plan would have to copy private plans’ bad behaviors.

When addressing liberal audiences, proponents of mandated private coverage with a public plan option conflate it with single payer reform, hoping to deflect criticism from their left. Meanwhile, Republicans warn that such a plan is a back door route to socialized medicine. Both are wrong.

Eight decades of experience teach that private insurers cannot control costs or provide families with the coverage they need. A government-run clone of private insurers cannot fix these flaws. It’s bad enough that insurers are peddling damaged goods. Why make things worse by requiring Americans to buy them?

Michael Goldfarb serves as a GlobalPost correspondent in the United Kingdom, where this article first appeared.

In America, the health care debate is about to come to a boil. President Barack Obama has put pressure on both houses of Congress to pass versions of his flagship domestic legislative program prior to their August recess.

Good luck.

Opponents are filling the airwaves with the usual litany of lies, damned lies and statistics about socialized medicine and the twin nightmare of bureaucratically rationed health care and high taxes amongst allies like Britain, France and Germany. So here is a brief overview of health care in some of Europe’s biggest economies: Britain’s National Health Service is paid for out of a social security tax. Services are free at the point of provision. No co-pay, no reimbursement. The budget last year was 90 billion pounds (about $148 billion). That makes the average cost per person about 1,500 pounds ($2,463).

The NHS is big — huge, in fact. With 1.5 million employees it is one of the largest employers in the world. Only China’s People’s Liberation Army, India’s state railways and good old Wal-Mart employ more folks. Sixty percent of the NHS budget goes toward salaries.

The French system is run on a compulsory purchase of insurance through the workplace. The insurance cost is based on how much a worker earns. Low-income workers pay nothing. The average contribution per person is about $4,000. The government sets fees for services and negotiates the price of drugs with pharmaceutical companies. (See related GlobalPost story “Why French doctors still make house calls.”)

Service is not free at the point of provision. But reimbursement for costs is swift and in the case of catastrophic illness all fees are waived. People are free to purchase supplementary insurance from private companies.

With a compulsory insurance plan, as in France, German care is universal and equitable. Germans pay approximately 14.3 percent of their earnings to buy this insurance. As in France, people are free to buy supplementary private health insurance. Each system is unique (as are all the systems around Europe) but they have two things in common that make them different from the United States: Coverage is universal and the cost of care as a percentage of GDP is significantly less.

For Europeans — even those who would label themselves conservatives — American attitudes to setting up a universal health care system with strong state participation and management seem bizarre. The peace of mind that comes from knowing that in an emergency you will be taken care of and you won’t be financially ruined has no price. Why resist it?

Beccy Ashton, policy adviser at health care think tank The King’s Fund, worked for more than half a decade in the U.S. She explains the difference this way: “In Europe healthcare is regarded as a human right. In America, people think of it as a commodity that you buy.” If you look at how the Big Three’s health systems came into being you realize changing American attitudes may be difficult.

Britain and France created their systems out of the rubble of World War II. Pushed from below, the leaders of both nations sought to bring greater social equality to their societies. Social security systems were set up with equal access to health care given pride of place.

This wasn’t done without facing down doctors and insurance companies, but politicians are never so bold as when the public will for something is clear. In 1945 in both Britain and France, there was no going back to the status quo before the war started. Germany’s system has the weight of history behind it. Its origins can be traced back to the first era of German unification when Chancellor Otto von Bismarck created the First Reich. In the 1880s he set up a system of compulsory health insurance by workers and employers and other forms of social security. He did not invent the system out of nothing. There had been a tradition among the German guilds going back to the Middle Ages of members making compulsory contributions to help their brothers in old age or if a colleague had to stop working because of injury.

Clearly, America at this moment in time has not recently experienced an epoch-shattering historical event like a World War and despite Obama’s comparative popularity, he doesn’t have the clout of an Iron Chancellor to simply decree what he wants and know that Congress will rubber stamp it.
Beccy Ashton points out, “The President must be aware of the fine line he has to walk. If he goes forward with a radical agenda, he knows you’ve lost before you’ve started.”

So people in Europe continue to watch with bemusement as American legislators grapple with reforming a system that basically needs to be junked. Professionals like Ashton answer calls from reporters and try to refute right-wing misinformation that floats around the debate. Those damned lies and statistics.

The only statistics on health care systems that really matter are life expectancy and infant mortality. Both speak to accessibility and affordability. If you want to know how the U.S., the wealthiest nation on earth, stacks up, here you go:

In life expectancy, the U.S. ranks 38th or 45th depending on whether one uses the United Nation’s statistics or those compiled by the CIA. (In both cases, life expectancy in Cuba is higher!) According to the CIA World Factbook, the U.S. has many more infant deaths than its EU counterparts or northern socialist (to right-wing ideologues) neighbor, Canada. While the U.S. has 6.26 deaths per live births, Canada had 5.04. Britain, France and Germany? 4.85, 3.33 and 3.99, respectively.

Other health links from GlobalPost:

Winter in the time of swine flu

Coming home from school with strawberry condoms

(Pictured above: Healthcare reform supporters rally outside U.S. Senator Sam Brownback’s office in Overland Park, Kansas, July 9, 2009. REUTERS/Carey Gillam)