U.S. Faces Shortage of Doctors - WSJ.com

As Ranks of Insured Expand, Nation Faces Shortage of 150,000 Doctors in 15 Years

By SUZANNE SATALINE And SHIRLEY S. WANG

Getty Images

First-year resident Dr. Rachel Seay, third from left, circumcises a newborn in George Washington University Hospital's delivery wing on March 12.

The new federal health-care law has raised the stakes for hospitals and schools already scrambling to train more doctors.

Experts warn there won't be enough doctors to treat the millions of people newly insured under the law. At current graduation and training rates, the nation could face a shortage of as many as 150,000 doctors in the next 15 years, according to the Association of American Medical Colleges.

That shortfall is predicted despite a push by teaching hospitals and medical schools to boost the number of U.S. doctors, which now totals about 954,000.

The greatest demand will be for primary-care physicians. These general practitioners, internists, family physicians and pediatricians will have a larger role under the new law, coordinating care for each patient.

The U.S. has 352,908 primary-care doctors now, and the college association estimates that 45,000 more will be needed by 2020. But the number of medical-school students entering family medicine fell more than a quarter between 2002 and 2007.

A shortage of primary-care and other physicians could mean more-limited access to health care and longer wait times for patients.

Proponents of the new health-care law say it does attempt to address the physician shortage. The law offers sweeteners to encourage more people to enter medical professions, and a 10% Medicare pay boost for primary-care doctors.

Meanwhile, a number of new medical schools have opened around the country recently. As of last October, four new medical schools enrolled a total of about 190 students, and 12 medical schools raised the enrollment of first-year students by a total of 150 slots, according to the AAMC. Some 18,000 students entered U.S. medical schools in the fall of 2009, the AAMC says.

But medical colleges and hospitals warn that these efforts will hit a big bottleneck: There is a shortage of medical resident positions. The residency is the minimum three-year period when medical-school graduates train in hospitals and clinics.

There are about 110,000 resident positions in the U.S., according to the AAMC. Teaching hospitals rely heavily on Medicare funding to pay for these slots. In 1997, Congress imposed a cap on funding for medical residencies, which hospitals say has increasingly hurt their ability to expand the number of positions.

Medicare pays $9.1 billion a year to teaching hospitals, which goes toward resident salaries and direct teaching costs, as well as the higher operating costs associated with teaching hospitals, which tend to see the sickest and most costly patients.

Doctors' groups and medical schools had hoped that the new health-care law, passed in March, would increase the number of funded residency slots, but such a provision didn't make it into the final bill.

"It will probably take 10 years to even make a dent into the number of doctors that we need out there," said Atul Grover, the AAMC's chief advocacy officer.

While doctors trained in other countries could theoretically help the primary-care shortage, they hit the same bottleneck with resident slots, because they must still complete a U.S. residency in order to get a license to practice medicine independently in the U.S. In the 2010 class of residents, some 13% of slots are filled by non-U.S. citizens who completed medical school outside the U.S.

One provision in the law attempts to address residencies. Since some residency slots go unfilled each year, the law will pool the funding for unused slots and redistribute it to other institutions, with the majority of these slots going to primary-care or general-surgery residencies. The slot redistribution, in effect, will create additional residencies, because previously unfilled positions will now be used, according to the Centers for Medicare and Medicaid Services.

Some efforts by educators are focused on boosting the number of primary-care doctors. The University of Arkansas for Medical Sciences anticipates the state will need 350 more primary-care doctors in the next five years. So it raised its class size by 24 students last year, beyond the 150 previous annual admissions.

In addition, the university opened a satellite medical campus in Fayetteville to give six third-year students additional clinical-training opportunities, said Richard Wheeler, executive associate dean for academic affairs. The school asks students to commit to entering rural medicine, and the school has 73 people in the program.

"We've tried to make sure the attitude of students going into primary care has changed," said Dr. Wheeler. "To make sure primary care is a respected specialty to go into."

Montefiore Medical Center, the university hospital for Albert Einstein College of Medicine in New York, has 1,220 residency slots. Since the 1970s, Montefiore has encouraged residents to work a few days a week in community clinics in New York's Bronx borough, where about 64 Montefiore residents a year care for pregnant women, deliver children and provide vaccines. There has been a slight increase in the number of residents who ask to join the program, said Peter Selwyn, chairman of Montefiore's department of family and social medicine.

One is Justin Sanders, a 2007 graduate of the University of Vermont College of Medicine who is a second-year resident at Montefiore. In recent weeks, he has been caring for children he helped deliver. He said more doctors are needed in his area, but acknowledged that "primary-care residencies are not in the sexier end. A lot of these [specialty] fields are a lot sexier to students with high debt burdens."

Related articles by Zemanta

• Why increasing medical school enrollment is not enough (medrants.com)
• Finding Good Migraine Care a Headache for the Uninsured (nlm.nih.gov)
• States may have to expand nurses' role to cope with doctor shortage (hotair.com)
• The Politically Inconvenient Medical Realities of Opting Out (benzinga.com)
• Temporary fix helps patients around drug allergy (ctv.ca)
• Consult A Doctor, Inc. Names Retail Clinic Pioneer, Douglas Smith, M.D. as Chief Medical Officer (prweb.com)
• Medicine residency survival tips during pregnancy (kevinmd.com)

This Won’t Hurt a Bit

Cover via Amazon

How we can save billions by cutting out unnecessary procedures that kill tens of thousands a year.

By Sharon Begley | NEWSWEEK

Published Mar 5, 2010

From the magazine issue dated Mar 15, 2010

When the White House and Congress were struggling last year to keep the cost of health-care reform from exploding, they got most of the industry to ante up. Pharma agreed to give up $80 billion in revenue over the next decade, hospitals kicked in $155 billion in foregone Medicare and Medicaid payments, and medical-device makers grudgingly agreed to a $20 billion tax. But one big player refused to put any money on the table: doctors. The American Medical Association pledged to support health-care reform only if its members' incomes didn't take a hit.

That doctors demanded protection for their wallets strikes Howard Brody, a family physician at the University of Texas Medical Branch, as "ethically questionable," and not only because he thinks doctors have a moral obligation to help get the nation's health-care bill under control. The bigger problem is that "doctors rip off the system with inappropriate care," says Brody. An estimated one fifth to one third of U.S. health-care costs, at least $500 billion a year, goes toward tests and treatments that do not benefit patients—routine CT scans in the ER, antibiotics for colds, Pap tests for women who do not have a cervix, and …

What comes after the ellipsis is the question of the hour. Brody recently proposed, in The New England Journal of Medicine, that every medical specialty identify five procedures—diagnostic or therapeutic—that are done a lot and cost a lot but provide no benefits to some or all of the patients who receive them. Five is just a suggestion, high enough to be meaningful but low enough to exclude procedures in which the science is still open to debate, such as annual mammograms for women under 50. "I'm pretty convinced that each specialty could come up with 15 or 20, but in calling for five I think we can find uncontroversial ones," says Brody. It's not just about saving money, either. Any time a doctor performs a procedure, there is the risk of medical error and side effects, such as an elevated risk of cancer from CT scans. Unnecessary care kills 30,000 Americans every year, estimates Dr. Elliott Fisher of Dartmouth Medical School—and that figure includes only Medicare patients.

Medical groups have not exactly beaten a path to Brody's door, so NEWSWEEK contacted several to see if they would play along. Reactions ranged from "we do no unnecessary care" (dermatology) to "only five?!" (emergency medicine). Allen Lichter, CEO of the American Society of Clinical Oncology, nominates what he calls "nth-line therapy"—the third or fourth or fifth chemotherapy drug for a patient whose cancer has not been felled by the first or second. "I don't know what n should be," he says. "But at some point chemotherapy has an extremely low chance of extending life and a high chance of shortening life due to toxicity."

Experts in internal medicine are already well along in identifying items for Brody's list. "I hate to say it, but it's true: doctors sometimes do things that do not benefit patients and can even be harmful," says Stephen Smith of Brown University medical school, who is spearheading the effort. Nominations, all from physicians, include antibiotics for upper-respiratory infections (the drugs kill bacteria, not the viruses that cause colds), Pap tests for women under 21 ("solid research shows that they find things that lead to unnecessary interventions but would clear up on their own," says Smith), and me-too drugs that are no more effective than older versions (anything other than diuretics for first-line treatment of high blood pressure).

High-tech tests are also in Smith's crosshairs. For coronary calcium scans, he says, "there is no evidence they lead to better outcomes. In low-risk patients, high coronary-artery calcification still means the patient is at low risk for heart disease and nothing needs to be done other than the usual 'heart healthy' behaviors. In a high-risk patient, aggressive efforts at reducing risk factors need to be undertaken regardless of the coronary-artery calcification." Similarly, thyroid testing in a patient with no symptoms "rarely yields an abnormal result," Smith says, and so "is not worth doing" on a symptom-free patient. Smith's team will "field test" these and other nominees this spring by asking hundreds of doctors if they agree. Eventually, docs who pledge to avoid unhelpful procedures might display some sort of emblem.

Smith's group is also considering nixing X-rays and MRIs for lower-back pain: the scans often spot something that is unrelated to the pain. About 80 percent of adults over 40 have a bulge or other deformation in their lower back that makes surgeons think "operate"—but no pain. So when such an "abnormality" shows up on a CT or MRI, attributing a patient's pain to it is probably nonsense. In fact, the vast majority of lower-back pain is caused by muscle sprains and strains that don't show up on scans, and for which surgery is no more effective (and is more dangerous) than over-the-counter pain meds, time, rest, and exercise. Although lower-back pain typically resolves within six weeks, many patients refuse to wait, and surgeons and radiologists have financial incentives to see that they don't. A 2009 study found that Americans spent $85.9 billion for imaging, surgery, drugs, and doctors' visits for lower-back pain—most of it for no benefit. "The use of MRI within six weeks of the start of lower-back pain is not only not useful, but it increases the number of surgeries, treatments, and costs," says anesthesiologist Ray Baker, president of the North American Spine Society, whose members do those very things.

Baker, who "applauds" Brody's call to arms, believes there are enough data to "draw a circle around" other procedures that are his members' bread and butter. For instance, at least 351,000 spinal fusions were performed in 2007, reports the Agency for Healthcare Research and Quality, at a cost of $26.2 billion. Yet except in the tiny fraction of cases in which the pain is caused by fracture or tumor, they're useless—but financially irresistible, points out Shannon Brownlee in her 2007 book Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer. At $75,000 per spinal-fusion procedure, medical-device makers, hospitals, and surgeons have every reason to keep the gravy train rolling. "We doctors are extremely good at rationalizing," says Brody. "Somehow we manage to figure out how the very best care just happens to be the care that brings us the most money."

Doctors who want to eliminate unhelpful procedures have their scalpels aimed at several other surgeries. Brody nominates arthroscopic surgery for osteoarthritis of the knee. A 2004 study showed that it is no more effective at restoring mobility and reducing pain than sham surgery. In other words, all the benefits reflect a placebo response on the part of patients, who think, "Docs in surgical scrubs, high-tech surgery, gleaming OR—this will certainly help me." But orthopedic surgeons still do the surgeries, which cost about $6,000.

They are not the only physicians who ignore the findings of clinical trials. Two studies last year in the NEJM showed that vertebroplasty, in which cement is inserted through a needle into the spine to stabilize vertebrae, is no more effective at reducing pain and disability than fake surgery (anesthesia, small incision for the needle, no cement). That suggests it is the hope and expectations of patients, not the procedure, that help. Yet about 170,000 vertebroplasties are done every year, at a typical cost of $5,000. Surgeons protest that their vertebroplasty patients hug them in relief that their pain has vanished. But "we saw 'miracle cures' in the sham-surgery group, too," says David Kallmes of the Mayo Clinic, who led one of the studies.

Every year cardiac surgeons perform bypasses on thousands of patients who have one or two blocked arteries, and cardiologists do angioplasty (with and without stenting) on thousands more. But five large clinical trials have shown that, except in an emergency, inserting a stent (to prop open a clogged artery) does not reduce the risk of heart attack or death any better than treating with drugs first (and stenting only if the pain persists). Interventional cardiology nevertheless carries on to the tune of about 500,000 elective angioplasties a year, at $51,000 each, including in patients who should get drugs instead. Hospitals can get $20,000 from private insurers for angioplasty, Brownlee found, almost half of which is pure profit. "Advocates say, 'We do it differently' or 'The clinical trials focused only on particular populations of patients, and we do these surgeries only where appropriate,'?" says Nortin Hadler, professor of medicine at the University of North Carolina and author of the 2009 book Stabbed in the Back: Confronting Back Pain in an Overtreated Society. "These arguments walk a fine line between hubris and quackery."

No one is saying cutting back on unnecessary medicine will be easy. There is a reason for every procedure doctors perform. The fact that the reasons are sometimes financial or legal (protecting against malpractice claims) makes them no less powerful. Few doctors have the training in statistics and trial design to understand what the science says about various therapies. And many honestly believe their patients are different from those in a study that found no benefit from some procedure. But if they're right about that, points out Baker of the spine society, it means there are no data that the procedure benefits those patients.

Consumers, too, are a powerful force for unnecessary medical care. Parents insist the ER do a CT scan on a child who bumped her head; runny-nose patients won't leave their internist without a prescription for antibiotics. "In a busy practice, it's sometimes easier to write the prescription than to talk the mom out of it," says pediatrician Beth Pletcher of the University of Medicine and Dentistry of New Jersey. And the heart patient who doesn't believe that pills could possibly be as effective as surgery? "Angioplasties, stents, and bypass have attained 'entitlement' status," notes Hadler.

Why do insurers pay for unnecessary care? Partly because they're battle-weary, having been successfully sued for refusing to cover, for instance, high-dose chemo plus bone-marrow transplants for breast cancer—which turned out to be not just useless but, for thousands of patients, deadly. "The abrasion that would result from even more intervention by health-care plans becomes problematic," says Joe Singer, vice president for medical affairs at HealthCore, a subsidiary of the insurance giant WellPoint. Translation: insurers have had it with trying to refuse coverage for useless procedures, since they can simply raise premiums—yours and mine—to cover the cost.

Perhaps, since so much useless care reflects financial incentives, financial disincentives might reduce it. In a paper last month in PLoS Medicine, R. Scott Braithwaite of the New York University School of Medicine and colleagues suggested that insurance cover 100 percent of effective diagnostic tests and treatments, but little to nothing for less effective ones. You really think you need an MRI for the back pain that started last week? It's on your nickel.

Related articles by Zemanta

• Medicine We Can Live Without: How to Cut Costs Now (newsweek.com)
• Health reform needs to end fee for service medicine (kevinmd.com)
• Radiation from CT scans: Balancing risks and benefits (scienceblogs.com)
• The Nothing Cure: Taking the placebo effect seriously (ctv.ca)
• Why cancer screening is not a black or white decision (kevinmd.com)
• Doctor and Patient: The Doctor's Failure to Cut Costs (nytimes.com)
• Obama Promise of Health Care Cost Savings Through Efficiency Achieved by Innovative Teleradiology Company (eon.businesswire.com)

The Doctor Won’t See You Now

Image via Wikipedia

A critical shortage of primary-care physicians is yet another symptom of our ailing health-care system.

By Mary Carmichael | NEWSWEEK

Published Feb 26, 2010

From the magazine issue dated Mar 8, 2010

After taking a month to regroup, the White House has put health care back at the top of its agenda, asking Republicans for new ideas and trying to regain momentum for old ones. But last week's summit came down mostly to the same old talking points. And even if the president does manage to get some version of health-insurance reform passed in the next few months, he and the country are still going to be dealing with the related crisis of America's doctor shortage. Primary-care physicians, family docs, general practitioners—whatever you call them, they're the country's first line of defense, the ones responsible for promoting preventive care, finding ways to keep people from getting sick in the first place, and thus bringing down costs throughout the system. If every American went to one of these doctors regularly, health-care costs might come down as much as 5.6 percent a year, saving $67 billion, according to one estimate. Yet we don't have nearly enough doctors to make that happen, and fewer are being produced every year.

The annual number of American medical students who go into primary care has dropped by more than half since 1997. It's hard to get an appointment with the doctors who remain. In some surveys, as many as half of primary-care providers have stopped taking new patients. The other half are increasingly overworked and harried. Clearly we need to find a way to increase their ranks, and both the congressional health-care bills and President Obama's reform proposal make moves in that direction. But those efforts are somewhat limited, and a more comprehensive solution could be thwarted by the same thing that's stalled the rest of health-care reform so far: politics.

The reason behind America's doctor gap is a matter of money. The average income in primary care is somewhere in the mid-$100,000s, which sounds like a lot but is less than half what specialists such as radiologists and dermatologists make. Given that doctors may graduate with as much as $200,000 in med-school debt, it's easy to see why primary care started hemorrhaging recruits more than a decade ago and why radiology and other well-paid, high-tech specialties took off in popularity.

The field has since entered a vicious cycle. As fewer people have entered primary care, the doctors who are left have been forced by tight schedules to shortchange some patients, forgoing the long, meandering chats that used to be a big part of checkups in favor of 15-minute, checklist-style appointments. The close relationships that general practitioners once had with patients drew many idealistic students into the field. Now recruiters face an extra-tough sell: they have to convince bright young would-be docs to pursue a career that won't pay very well and won't be as emotionally fulfilling as it once was.

How can schools entice more aspiring doctors into primary care? The Tufts University School of Medicine, to take one example, offers a $25,000-per-year scholarship for med students who agree to work in primary-care practices in rural Maine for much of their training period. Students on this Maine Track start shadowing doctors on the third day of orientation. This year's program drew 257 applicants for just 36 slots.

The problem with the Maine Track is that it doesn't actually require med students to enter primary care after they graduate. It can't, says Peter Bates, chief medical officer at Maine Medical Center, which jointly administers the program with Tufts. "If you're a bright kid with a great future, being told you have to be a family physician in rural Maine—even if that's what you want to do [now]—might strike you as confining," Bates says. "Why would you close down your opportunities?"

There are dozens of training programs like Tufts's around the country, as well as the National Health Service Corps, which pays back loans and hands out scholarships and stipends in exchange for a few years of service in rural areas, where the shortage of primary-care providers is most acute. Obama and the Senate have both called for an expansion of the program in their proposals for reform, which has already received $200 million in stimulus funds. Several new medical schools, including some that focus on primary care, have also recently opened. But all those changes may not be enough to fill the gap. "We need more than half of doctors in this country doing primary care," says Harris Berman, interim dean of the medical school at Tufts. "It's a bigger problem than we can solve with programs like ours."

So what else can be done? Lately, some policymakers have argued that instead of having a primary-care doctor, more people—especially young, healthy patients with simple medical needs—should see a nurse or physician assistant who administers routine care and kicks more complex problems up to a doctor when they arise. "If you're just coming in to have your blood pressure checked and your pulse taken, you really don't need to see a doctor, and you might not need to see a nurse, either," says David Barrett, president and CEO of the Lahey Clinic in Burlington, Mass. "There are three-stripe military sergeants with two-year degrees who can provide excellent primary care. There's absolutely no reason to force all primary-care providers to have an M.D."

The Lahey Clinic is an "integrated group practice"—one of the teamwork-oriented organizations, like the Mayo Clinic and the Cleveland Clinic, that have been lauded for cutting costs and eliminating waste in the health system. In its primary-care service, a "team captain" physician supervises nurses, PAs, and other health-care professionals who perform tasks like checking blood pressure but don't necessarily make formal diagnoses on their own. The problem with taking this approach nationwide is that nurses and PAs are subject to the same economic forces that drive medical students. Almost half of current nurse practitioners and physician assistants work in specialty practices, where the money is. Then there's the fact that the country already has a nursing shortage. How are nurses going to replace doctors if there aren't enough nurses to begin with?

There's one more group of people, foreign medical graduates, who could theoretically fill in for the missing primary-care providers. The trouble is, they're already doing that. More than a quarter of primary-care doctors currently practicing in the United States have gotten their diplomas abroad. Increasing their numbers would be problematic for both the left (which might object to poaching doctors from developing countries that need them) and the right (which would surely object to recruiting non-Americans to do a job that reliably pulls in six figures, especially when unemployment is high).

Inevitably, then, the solution to the primary-care crisis is going to have to involve something simpler: paying primary-care providers more, so as to draw more bright young physicians into the field. At least it sounds simpler. But even this turns out to be maddeningly complex.

Most primary-care doctors, like all other physicians, are paid bit by bit for each medical task they perform (unless they work somewhere like the Lahey or the Mayo, which pay set annual salaries). Private insurers decide how much they'll reimburse docs for each task partly by looking to Medicare's policies for guidance. Medicare, in turn, makes its decisions by committee. Here is the bad news for primary-care docs: most of the physicians on the committee that sets the reimbursement rates are specialists. Medicare—and, consequently, private insurance—doesn't reimburse primary-care doctors as lavishly as it does their more specialized counterparts. That's why primary-care incomes are relatively low in the first place.

Changing anything about the way primary-care providers are paid will be immensely complicated. For one thing, rural doctors sometimes perform specialized procedures because no one else is available—would they still qualify for a raise? And then, what exactly constitutes a task that should be reimbursed? For a high-tech specialist, this is often clear-cut: each scan or chemical test counts. But what about all the things primary-care doctors do that don't involve technology? "You don't get paid to talk to people and tell them to stop smoking. Nobody values my time to do that," says Joe Gravel, a family physician and chief medical officer at the Greater Lawrence Family Health Center in Massachusetts. "They'll pay for the lung transplants, but they won't pay to prevent 50 people from needing them."

In January, Medicare raised reimbursement rates for some primary-care services by about 4 percent, and its payment committee will call for another small increase this week. That's a good start, says Lori Heim, president of the American Academy of Family Physicians, but "if you're talking about changing the way students view primary care, it needs to be more like 25 percent, and that's on the low side." Both the House and Senate reform bills also include a slight increase in primary-care payments—5 and 10 percent, respectively.

To fund such a pay raise, Congress would either have to spend more money on health care or pinch some from the specialists by lowering their pay rates. The first strategy is clearly controversial—no one wants to increase health-care costs further. The second, budget-neutral strategy is bound to tick off the specialists. Peter Mandell, a spokesman for the American Academy of Orthopaedic Surgeons, sent a clear message last year when the Medicare reimbursement committee suggested a 10 percent shift in payments toward primary-care docs and away from specialists. Telling The New York Times that his group had "a problem" with the idea, Mandell added, "If there's less money for hip and knee replacements, fewer of them will be done for people who need them." It's a short step from his polite, reasonable statement to rallies over the specter of rationing.

So here is the fundamental dilemma of the primary-care crisis: One of the solutions with the best chance of working is politically unpalatable, and even those who support it admit it's a bureaucratic nightmare. But without it,we may be heading for an even bigger disaster that nobody wants. Does this sound familiar? The cure for primary care, it turns out, is ultimately going to be the same thing that's needed to fix the rest of the health-care system: political will.

Pelosi’s Challenge - Corraling Votes for a Health Bill

By SHERYL GAY STOLBERG and ROBERT PEAR

WASHINGTON — The future of President Obama’s health care overhaul now rests largely with two blocs of swing Democrats in the House of Representatives — abortion opponents and fiscal conservatives — whose indecision signals the difficulties Speaker Nancy Pelosi faces in securing the votes necessary to pass the bill.

With Republicans unified in their opposition, Democrats are drafting plans to try on their own to pass a bill based on one Mr. Obama unveiled before his bipartisan health forum last week. His measure hews closely to the one passed by the Senate in December, but differs markedly from the one passed by the House.

That leaves Ms. Pelosi in the tough spot of trying to keep wavering members of her caucus on board, while persuading some who voted no to switch their votes to yes — all at a time when Democrats are worried about their prospects for re-election.

Representative Dennis Cardoza, Democrat of California, typifies the speaker’s challenge. The husband of a family practice doctor, he is intimately familiar with the failings of the American health care system. His wife “comes home every night,” he said, “angry and frustrated at insurance companies denying people coverage they have paid for.”

But as a member of the centrist Blue Dog Coalition, Mr. Cardoza is not convinced that Mr. Obama’s bill offers the right prescription. It lacks anti-abortion language he favors, and he does not think it goes far enough in cutting costs. So while he voted for the House version — “with serious reservations,” he said — he is now on the fence.

“I think we can do better,” Mr. Cardoza said of the president’s proposal.

Representative Frank Kratovil Jr., Democrat of Maryland, is also unconvinced. He voted against the House bill on the grounds that it is too big and too costly — a view that some constituents in his Republican-leaning district share. In case he did not get the message, one of them hanged him in effigy this past summer outside his district office on the Eastern Shore of Maryland.

“This system is broken; we have to do something,” Mr. Kratovil said. “But my preference would be to do smaller things.”

For the moment, there is no actual bill. The tentative plan calls for the both the House and the Senate to use a parliamentary device known as reconciliation to pass a compromise measure.

The tactic is intended to avoid a Republican filibuster, but in the Senate, the majority leader, Harry Reid of Nevada, faces challenges if he tries to use it. He is having trouble persuading a majority of his caucus to go along.

In the House, lawmakers like Mr. Kratovil, Mr. Cardoza and other swing Democrats will come under increasing scrutiny from leadership as a vote draws near. Of the 219 Democrats who initially voted in favor of the House measure, roughly 40 did so in part because it contained the so-called Stupak amendment, intended to discourage insurers from covering abortion.

Some, notably Representative Bart Stupak, the Michigan Democrat for whom the amendment is named, will almost certainly switch their yes votes to no because the new version being pushed by Mr. Obama would strip out the House bill’s abortion restrictions in favor of Senate language that many of them consider unacceptable.

An additional 39, like Mr. Kratovil, are fiscal conservatives who voted no the first time around. Ms. Pelosi is hoping that she can get some to switch those no votes to yes in favor of Mr. Obama’s less expensive measure.

But persuading Democrats who are already on record as opposing a health overhaul to do a turnabout will not be an easy task, especially during a midterm election year in which Democrats’ political prospects already look bleak. Of the 39 Democrats who voted against the House measure, 31, including Mr. Kratovil, represent districts that were won in 2008 by Senator John McCain of Arizona, Mr. Obama’s Republican rival. Fourteen, including Mr. Kratovil, are freshmen, who are generally considered more politically vulnerable than more senior lawmakers.

“The concern among Democrats right now is that there are more yes votes reconsidering than no votes,” said David Wasserman, who tracks House races for the nonpartisan Cook Political Report. “My sense is that for Democrats to pass this bill, they would have to convince several members who are already in serious jeopardy, even after voting no on the first health care bill, to put passage of the bill ahead of their own chances of being competitive in the fall.”

But politicians do not want to be martyrs. They want to hold onto their seats.

Ms. Pelosi is facing resistance from some of her most senior members, like Representative Ike Skelton, Democrat of Missouri and chairman of the Armed Services Committee. He has been in office since 1977, but is facing his toughest re-election challenge in years.

Mr. Skelton says he does not see any improvements in the measure that would cause him to vote in favor of it; like Mr. Kratovil, he favors a smaller, less ambitious bill. “It would be a lot easier,” he said, “if we cut this back to basics — take two or three or four issues on which everyone agrees and build on it.”

Others, like Representative Jason Altmire, a Pennsylvania Democrat who also voted against the House bill, seem to wonder aloud why Mr. Obama is bothering. With so many Democrats feeling nervous about their past votes in favor of the health bill, Mr. Altmire said, he can imagine vote-switching in only one direction: from yes to no.

“I don’t know of any no votes at this point that would switch unless the bill is substantially changed, including me,” he said. “And I know of a handful of yes votes who regret it and would relish the opportunity to put a no vote on the board so they could go back home and talk about that.”

Analysts like Mr. Wasserman say Ms. Pelosi’s best chances for no-to-yes conversions rest with Democrats who are retiring, because they do not have to worry about their political fortunes in the fall. So far, there are only three: Representative John Tanner and Representative Bart Gordon, both of Tennessee, and Representative Brian Baird of Washington.

Mr. Tanner has told colleagues he has no intention of switching his vote, according to one Democratic lawmaker who has spoken with him. And in interviews on Friday, Mr. Gordon and Mr. Baird sounded decidedly noncommittal.

Mr. Gordon said his constituents were “starting to get a little bit tired” of hearing about health care. He said he wanted to see “at least a partially bipartisan bill” — something that now seems impossible in the House, given that the lone Republican who voted in favor last time, Representative Anh Cao of Louisiana, has publicly changed his mind.

Mr. Baird said he was ”totally undecided” about whether he could support the new version taking shape in Congress, though he did say the bipartisan forum Mr. Obama conducted at Blair House on Thursday would “potentially” make him more likely to vote for the legislation, perhaps because Republicans seemed so dug in against it.

“At several points,” Mr. Baird said, “President Obama tried to find common ground, only to see the other side go back on message.”

Publicly, House Democratic leaders are trying to sound upbeat. The House Democratic whip, Representative James E. Clyburn, Democrat of South Carolina, said last week that he felt ”pretty good” about the chances of passing Mr. Obama’s bill. But the leadership has not yet started counting votes, and a senior House leadership aide, speaking on condition of anonymity, conceded that rounding them up would not be easy.

“It’s going to be a heavy lift,” this aide said, ”but so have many other votes. In the last health care vote we really didn’t have the majority until the afternoon, and this will probably be that way too. That’s how these votes come together in the end.”

Carl Hulse contributed reporting.

Is There Life in Health Care Reform?

By Elizabeth Drew

In politics, as in life, there's often a very fine line between a fluke and an earthquake. They can even be mistaken for each other. In many ways, Scott Brown's upset victory over Martha Coakley on January 19 for the Senate seat long held by Edward M. Kennedy, just as Congress was nearing agreement on the health care bill, was a fluke. The confluence of seemingly unrelated events had more impact than any of them would have had individually. Even the date of Kennedy's death last August had major consequences: if it had happened a month later, the President might already have signed a health care bill into law by the time the election was held. A senior Democratic House strategist told me, "Had we known that Massachusetts was in play, we'd have worked through the Christmas break and might well have been done before the election." The bills passed by the House on November 7 and by the Senate on the day before Christmas were quite similar. (Nancy Pelosi and Harry Reid and their aides, in consultation with the White House, had seen to that.)

As a result of intensive negotiations in early January, the bills were more than 95 percent alike by the time of the Massachusetts election. Two major issues remaining had to do, first—thirty-seven years after the Roe decision establishing abortion as a constitutional right—with Congress having adopted provisions in the health care bill that make it difficult (the Senate) or even impossible (the House) for women who received federal help to purchase abortion coverage with their own funds (really!); and, second, with excise taxes on the more expensive ("Cadillac") plans, which labor objects to.

---

---

Republicans had applied the theory that the longer a bill is delayed, the weaker it becomes. Their real goal was to kill it. They gave Senate Finance Chairman Max Baucus just enough encouragement that he engaged in a months-long effort to get Republican backing for the bill. The idea, shared by the White House, was that a bill with bipartisan support would have more legitimacy with the public; but the negotiations kept going long after it was clear that the Republicans didn't want to help. (He got the vote in committee of Maine's Olympia Snowe, who made a big show of her reluctance to give it—the diva who wouldn't leave the stage—and then voted against the bill on the Senate floor.) Finally, even the White House gave up on Baucus and scheduled Obama's speech to Congress on health care on September 9, to encourage his committee to wrap it up. By the time the Senate finally passed its bill on Christmas Eve, Coakley was losing altitude, but no one seemed to notice.

An election outcome is usually caused by a number of factors, but national observers tend to look for national implications. In fact, Coakley broke a fundamental rule of running for office. Having swept the primary, she took the final election, five weeks later, for granted. As a Democratic senator said to me afterward: "There's a saying that there are only two ways to run: unopposed or skeered." He added, "She wasn't unopposed." Though she had run for the nomination on the fashionable demand for "change," the handsome, sly, and wily Brown beat her at her own game. Because no one realized in time that it was a real race, there were no exit polls, but a telephone survey by the highly respected Hart Research Associates on the night of the election called it "a working-class revolt," saying that the survey "reveals to Democrats [the cost]of not successfully addressing workers' economic concerns." Yet the survey also concluded that by a two-to-one majority, voters said they decided on the basis of the candidate, not because they were "sending a message to Washington."

The Hart firm also interpreted the results as "not a call to abandon national health care reform," pointing out that "Brown actually lost among the 59 percent of voters who picked health care as one of their top two voting issues." It was another fluke that Massachusetts was the only state with a comprehensive health care program, which Brown had supported, but he said therefore he didn't want the people of Massachusetts to pay for the health care of people in other states.

Nevertheless, many people jumped to the conclusion that the election was a rejection of the pending health care bill. The bill itself, its perceived shortcomings and flaws notwithstanding, stood to be the greatest advance in health care coverage for Americans in decades, if not ever. At least 30 million more people would receive coverage; those who could not afford health insurance would receive subsidies; those with coverage would be relieved of the worst depredations of the health insurance industry, such as rejecting people on the grounds that they had "preexisting conditions" or cutting off care of a patient because it was becoming too costly. Access to Medicaid would be significantly expanded. Presumably a start would be made on getting some control over the ever-burgeoning health care costs to this country. Moreover, it could be the last chance for significant health care reform for a long time.

Even before the Massachusetts election, it was evident that progressives were probably at the peak of their political power for some time to come: typically, the party of first-term presidents loses seats in the midterm elections, and the outlook for the Democrats in 2010 was already ominous. Elections in 2009 for governor in Virginia and New Jersey, as well as various polls, indicated that independents, who had swung the 2008 election to Obama, were leaving the Democrats in droves. And the closer a controversial bill gets to the midterm elections, the more the incumbents become uneasy about it. This is why Obama, who had campaigned hard on the issue, made it his first domestic priority; key figures on Capitol Hill told the White House that it was reasonable to expect Congress to pass it by August 2009.

Even though until the Massachusetts election the Democrats held sixty Senate seats (the first time a party had done so for thirty years)—just enough to shut off a filibuster—the Democrats themselves were divided in their degree of support for the bill, with some seeming opposed, and some, such as Blanche Lincoln, of Arkansas, facing daunting reelection challenges, while the Republicans were united against it. Therefore, Harry Reid and the White House had very little room to maneuver. And while Nancy Pelosi had a more progressive caucus, it was not enough to get bills through the House without the support of some moderate or conservative Democrats. (Hence she had to accept the harsh anti-abortion restrictions of the cartoonish Congressman Bart Stupak of Michigan.) In sum, in the Senate we have a parliamentary system, which depends on party discipline, but not majority rule; it's not a workable system.

Therefore, while the health care bill could be changed at the margins, at some point the question became not whether the bill would meet most of the progressives' expectations but whether there would be a bill at all. It was a lot easier for progressive critics to attack the bill, and say that it should be significantly changed—arguing in particular that it should not rely so much on the flawed existing private insurance system—than it was to find sufficient votes to change it. The bill that emerged from the Senate probably went about as far as could be expected, in view of the political realities. Sheldon Whitehouse, a freshman Democrat from Rhode Island who is widely seen as increasingly influential in the Senate, told me, "The vast majority of Democratic senators pushed the more conservative members of the caucus about as far as they could be pushed. We couldn't get any more from our more insurance-oriented members." As for Obama's role, Whitehouse said, delicately, "I don't think the President would add much to the equation. I think the internal pressures of the caucus took it about as far as it could get."

Yet numerous critics in and out of Congress publicly denigrated the bill for not going far enough. Howard Dean, who obviously delighted in the television attention he was getting, and who certainly should have understood the reality, called the Senate bill without the much-discussed public option (for which it was clear from the outset that there weren't enough Senate votes) "a farce." In mid-December, he urged, recklessly, that the Senate should set the bill aside and start over. Under pressure from annoyed Democrats, he backed off.

Opinions about the significance of the public option were mixed. Some influential reform advocates didn't believe that it was so critical, and thought that its advantages could be made up in other ways, in particular through rules governing the insurance exchanges that were to be set up—but they didn't want to say so out loud for fear of alienating the Democratic left. Even some senators who preferred the public option but knew that there weren't the votes for it said privately that it had been made into an "icon," blown out of proportion. This was the calculation that Obama made: he sometimes gave it lip service in order to appeal to his base, but never really fought for it.

The Republicans had decided even before Obama was sworn in that they would use the rules to deny him success on every major issue. Such obduracy was without precedent in modern times. Even if they hadn't gone that far, it would have been impossible for Obama to achieve the bipartisanship he had so easily and naively promised in the campaign. The days of bipartisanship were already long gone. For sociological and political reasons, the electorate had changed; the center had just about disappeared. Former Senate Majority Leader Tom Daschle says that the last time the Senate acted in a spirit of comity was in the 1980s. The situation of 2009–2010 is different: it's not a matter of the two parties being unable to compromise on the substance of policy; it's a matter of one party deciding to deny the other any political achievements at all.

A stunning example occurred in late January. After Obama said he would support a proposed bipartisan fiscal commission, which would recommend politically difficult cuts in the federal budget, to be voted up or down by Congress (along the lines of the base-closing commission), seven Republicans who had sponsored the proposal actually voted against it—enough to defeat it. Obama said he would set up a commission by executive order, but it won't have the same power, and some key Republicans announced that they would boycott it.

Because of the filibuster rule, it's been assumed for many years that anything controversial, even bringing up a bill for debate, needs sixty votes (sixty-five until 1975). In the past, filibusters, or threats of them, had been made by a faction of the Senate, or of a party, or by representatives of a region (Southerners opposed to civil rights bills), and motions to end filibusters were usually bipartisan. When the health care bill was before the Senate, with all the Republicans lined up against it, the Democrats' needing sixty votes meant that every single member of the Democratic Senate caucus was a potential king or queen. Each senator was in a position to make demands, or to threaten to kill the bill. More of them behaved this way—putting themselves ahead of the greater good—than might have been expected. Each time, the White House and the Senate leadership had to decide between accepting an undesirable amendment or letting the bill die.

The Republicans have long been more respectful of hierarchy than the Democrats; this tendency was greatly enhanced after Newt Gingrich and his allies took over the House in the 1994 midterm elections and methodically accrued more and more power to the Speaker's office. As Gingrich's acolytes moved to the Senate in large numbers, they took with them their ways of exercising power and their scrappiness, their disdain for traditional Senate comity. And the Senate Republicans have their own ways of enforcing discipline. In mid-December 2009, Republicans were threatening to filibuster the defense appropriations bill for the acknowledged purpose of delaying consideration of the health care bill, which was to follow. (They were thus holding up pay and supplies for the troops fighting in Iraq and Afghanistan; if the Democrats did that, they would be charged by the Republicans with treason.)

The Democrats believed that they had a deal with Thad Cochran of Mississippi, the senior Republican on the Defense Appropriations Committee and widely admired as a courtly and honorable man, to adopt some amendments he wanted to the defense bill; in return he would provide the sixtieth vote to shut off the filibuster on defense appropriations. (One Democrat was holding out on this vote.) But then the Senate Republican leaders, in particular the dour whip John Kyl of Arizona, leaned heavily on Cochran, telling him that the Republicans had to stick together and make the Democrats come up with their own sixty votes. "It was kind of an agonizing ordeal for me," Cochran told me later.

In some instances, Republicans who might shun the leaders' demands are given indications that their future committee assignments might be affected; and they can be made to feel very lonely in conference meetings. Cochran's Democratic colleagues watched in amazement as the last man they thought wouldn't keep his word quietly raised his hand to cast his vote (he couldn't even say it) against shutting off the filibuster on the defense bill, and quickly left the Senate floor. If the Republican leadership is willing to treat Cochran—who is third in seniority among Senate Republicans and would be chairman of the Appropriations Committee if the Republicans were in the majority—in this way, it's not hard to imagine how more junior members are treated.

The President, his aides, and other leading Democrats were already aware that rage was building among voters as a result of the same facts that were frustrating the administration: despite all its efforts, the bailouts, and the stimulus, unemployment remained high. Though gains had been made, fear that the recovery wasn't real was holding it back. A major economic adviser to the President told me not long ago that by November 2010 unemployment might well reach above 10 percent because, as the economy presumably improved, more people who had stopped looking for work would reenter the job market.

Though Obama had in fact achieved more than any recent president in his first year in office, and his personal popularity remained relatively high, his approval rating was falling fast, and he was widely seen as a failing president. Obama was getting more criticism than credit for his actions to keep the economy from falling into a depression—a subject that hadn't come up in the campaign—and in his State of the Union address in late January he distanced himself as far as possible from the bank bailout. ("I hated it. You hated it.") Still, White House aides understood that—"not without reason," one adviser told me—much of the public saw the Obama administration, as the saying went, as more concerned about Wall Street than Main Street.

Some of Obama's achievements were simply lost in all the hubbub over the health care bill. Some were simply confused with one other (many thought the stimulus bill and the bailouts were the same thing). Obama was proving at risk of fitting that most dangerous of political descriptions: a disappointment. His campaign aides had portrayed him as a "transformational figure" who would have a vast following ready to march for him, helping him pass his legislation. But this following didn't materialize once he came to office, in part because people who had set aside time to help him win the presidency had other things to do with their lives, in part because the Obama administration has been neither well organized nor effective at summoning the predicted following for his programs. Obama seemed to have lost his magic.

There's no question that the health care bill was sinking in popularity before the Massachusetts vote (but it was not, as Brown said recently on ABC's This Week, "on its last legs"). The interesting question is why it was losing support. In an NBC/Wall Street Journal national poll shortly before the Massachusetts election, only 33 percent of the public approved of Obama's health care plan. Yet this same poll indicated that 40 percent of the respondents wanted reform efforts to do more, not less. My own view is that it was their impression of what happened as much as what actually was going on that caused so many people to turn against it. The process became confused with the substance. The analogy between legislating with sausage-making fits here particularly well—"People who love sausage should never see it made." The legislating on the health care bill was widely followed in the media; people saw the sausage being made.

Moreover, a number of people behaved very badly, showing for all the world to see that they put themselves ahead of the greater good. (Not all did, by any means, but enough to disgust the public.) Getting attention and taking home as much bacon as possible (even at the expense of other states and the bill itself) and ideological posturing (pushing for something that had no purpose except being divisive and getting the legislator proposing it on television as a result) were too much in evidence. Inevitably, much of the public became fed up—forgetting the purpose of the whole enterprise. Perfectly intelligent people told me that they no longer cared whether the health care bill passed after Ben Nelson of Nebraska, a conservative Democrat (and former insurance executive) who used his necessary sixtieth vote to great advantage (he had already been complicit in modifying the stimulus bill for the worse), arranged to get his state exempted from paying fees for the expanded Medicaid program. (This followed the "Louisiana Purchase" by which Mary Landrieu obtained an extra $300 million in Medicaid money for her state.)

People shocked by these arrangements overlooked that such deals, if not of this magnitude or open brazenness, take place all the time. But the Nelson deal caught people's attention and blew it out of proportion; watching the health care bill move through Congress was like being in a hall of mirrors in a fun house. Everything, it seemed, was distorted. Nelson, however, got flack from his own state because he had gone too far, and after a while tried to get rid of the amendment, but because of the legislative impasse he was stuck with it. What were Senate leaders or White House aides thinking about when they accepted Nelson's ransom demand? Or Joseph Lieberman's rejection of a proposal to expand Medicare coverage? (Lieberman, though he got there first, was not alone in his opposition.) They were asking themselves, one of them told me, whether it was worth rejecting these proposals, only to lose the bill.

But citizens who were so turned off by the Nelson deal that they were ready to give up on the health care bill weren't adequately informed about the bill itself, and this gets back to the treatment of the health issue in the press and on television and the Internet. The Nelson story was a big story; what was in the health care bill was not. The messiness and the anger on Capitol Hill were the story. The media also had a large part in polarizing the public over the bill. As cable outlets and blogs become more ideological, on both the left and the right, people have become more inclined to seek out the ones they agree with. And the outlets stir up ratings through exaggeration and combat.

Though Obama never submitted his own bill—which might have helped but he didn't want to be seen losing on some of its provisions—he said again and again what he wanted the health care bill to be, or what it was, but the press didn't think that was news. What good the bill would do, even what it would do, didn't fit in with the story the press wanted to tell. The people who appeared most often as guests on television—to the point of aching tedium—were those who had objections to the bill, particularly those on the left such as Dean, and Anthony Weiner, a New York House member, who complained repeatedly about the absence of the public option, long after it was clear that the Senate wouldn't accept it; and the Socialist-Independent Bernie Sanders, who clung to the fantasy of turning the whole thing into a single-payer system. One unfortunate upshot of Obama's decision not to get very involved publicly until the final negotiations was that his presidency became too defined by the goings-on on Capitol Hill, the deal-making. The clear impression was that Obama was not leading.

Obama's and his administration's performance on the day after the Massachusetts Senate election was dismaying. Obama told George Stephanopoulos in an ABC interview that morning that the White House had seen Coakley's loss coming for a week, but they clearly weren't prepared. They lacked both talking points and strategy, and the result was a mess. First, the President mentioned a legislative procedure, although no one knew what he was talking about, and then he made matters worse by suggesting that the bill might have to be pared down to its more popular parts, which was not only an early retreat but would be more difficult than it sounded, because the bill's main parts were in equipoise.

Popular insurance reforms, such as guaranteeing that no one would be rejected because of preconditions, were interconnected with ways to pay for them—by guaranteeing insurance companies more customers, which required a mandate to buy insurance policies. This, in turn, would require subsidies for those who couldn't afford insurance. Obama's press aides spent the rest of the day cleaning up after him, by saying that the President still preferred that Congress pass a major health care bill. The absence of a clear statement from the White House led panicked Democrats on Capitol Hill to make contradictory and often incoherent comments.

A similar thing happened with the President's speech to a Democratic National Committee meeting on February 4, in which he suggested a time-consuming process, and the possible outcome that the bill could die. Once again, aides had to fan out to clarify that Obama still wanted a bill, and I'm reliably told that there are meetings at the White House every day on how to salvage the bill.

The problem isn't, as this White House, like many before it, concluded, that it wasn't "communicating": it communicates all the time, sending aides out to deliver messages on talk shows and putting the President before the cameras (and TelePrompters, which should go) all the time. The problem is that they convey contradictory messages and that the President is far better at rhetorical eloquence than he is effective at explaining what needs to be done. He sometimes ruminates—and gets in trouble. White House aides complain that the press "overinterprets" what the President says, but by now the Obama White House should understand that that's how it works.

And Republicans seem to win the "talking points" time and again. The wise Vin Weber, a former Republican congressman and now a lobbyist, says that the problem isn't that the Republicans are so much better than the White House at creating "talking points," but that "it's very difficult to put together positive talking points on health care. It's very complicated. In fact, it's very hard to find a time when health care was a winning political issue." Weber recalled the famous incident when, after Congress in 1988 had passed a bill to provide Medicare coverage, for a fee, for catastrophic care, House Ways and Means Chairman Dan Rostenkowski, its chief sponsor, was chased away in his car by an angry Chicago mob; three months later the bill was repealed. So administrations trying for health care reform tell themselves, as the Obama administration has done, that people would like the bill when it came into effect and would then stop focusing on the bad things it might do.

Mostly for financial reasons, however, the main part of the current health care bill wasn't to go into effect until 2014. So the administration came up with a list of "deliverables"—advantages they could give people before then. But through repetition and lies, the Republicans were winning the propaganda debate. Time and again, they spoke of a "government takeover of health care." On the night the House passed the bill, Minority Leader John Boehner engaged in a long rant that included warnings that people would go to jail if they didn't buy health insurance. Meanwhile, the White House's rationale for the bill wandered from being a way to reduce the deficit, to a way to protect consumers, to a moral imperative, to, more recently, something that would produce jobs.

By the time of the State of the Union address, the President and his aides had wanted to "pivot" from health care to legislation to provide more jobs; the dragged-out consideration of the health care bill had been agonizing for them, as well as politically damaging. So he pivoted anyway. Advocates of health care reform complained; but in the midst of all the commotion about the Massachusetts election and the evidence of a working-class revolt, Obama would have looked like the doofus he isn't had he led off with yet another argument for health care. But he insisted that he hadn't given up on it, because not to succeed would be a political disaster for him—and as he pointed out in the speech, "I know this problem is not going away."

Obama was also criticized for not laying out in his speech a strategy for how to get a final health care bill, but there was no strategy. By this time, the House and the Senate, between which there have long been institutional tensions, were nearly at war. The House had passed some politically difficult bills (cap and trade to lower carbon emissions, regulatory reform of Wall Street, another jobs bill) that were lying dormant in the Senate. House Democrats were steamed up and threatening not to take up certain bills, such as immigration reform, until the Senate had done so.

Now that the Senate Democrats had lost their sixtieth vote, working out a final health care bill had become vastly more difficult, as a number of other things promised to be. (To rub it in, Scott Brown got himself sworn in a week earlier than planned, on February 5.) Without sixty votes, the Democrats couldn't simply reopen the Senate bill to incorporate the changes that the Democratic House and Senate leaders had agreed upon. Instead, the Senate Democrats wanted the House to adopt the Senate bill, and then both chambers would adopt a "reconciliation" bill (which would require just fifty-one votes in the Senate) that would include most of the final changes.

But House Democratic leaders, mistrusting the Senate—and not liking it, either—balked at doing that. Pelosi stated definitively that she couldn't get enough House votes to pass the Senate bill, unless the Senate passed the reconciliation bill first. And the Senate said that the rules made it impossible to adopt the reconciliation bill first (the House disagreed). Some of the changes couldn't be put in the reconciliation bill, which can only deal with matters that affect the budget. This would call for a third bill, which no one knows how to pull off.

Logically, there should still be a way to get a bill passed. But logic went out the window on January 19. The situation was as much psychodrama as legislative stalemate. The perfectly reasonable argument was made to Democrats in Congress, mainly by the administration, that, having voted for the bill already, it would be worse for them to fail to pass it than to pass it, but this seemed not to be heard. If Obama didn't exert himself for the bill on which he'd spent most of his time in office thus far, it would be not just a political catastrophe for him but leave a scar on his presidency. Longtime observers—members of Congress and people who deal with them—say they have never seen such a sour mood on Capitol Hill, affecting both members and staff alike. One longtime Democrat said to me recently:

The moderates are paranoid, the liberals are upset, the leaders are frustrated and losing the trust of everybody. There's no level of trust between the Senate and the House or the White House and everyone else. There has been a breakdown of the kind of chemistry you need to get this kind of thing done.

The opportunity might have been lost as a result of a misreading of a fluke in Massachusetts. To successfully remedy this misreading would require a certain amount of will, but, at least in the Senate, whatever will had been present appears to be fading. A senior Senate Democratic aide said to me at the end of the week after the election, "There isn't a member of our caucus that isn't concerned after what happened last week." A few days later the same person sent me the following e-mail:

Every option is bad. The leaders in the House and the Senate want to get a bill but enthusiasm is waning in the rank and file. They want us to focus on jobs. Still think we can get it done but have no idea how.

Obama's move to take the issue to the Republicans by inviting them to a half-day, bipartisan meeting at Blair House on February 25 to discuss health care—without, as the Republicans had been insisting, scrapping the pending bill and starting over—was intended to show the public (and wobbly Democrats) who the obstructionists are. (And Obama's recent televised meeting in Maryland with House Republicans had been a big hit.) The invitation was also intended to answer public criticism, now registering in the polls, of "backroom deals" (Landrieu, Nelson) and Republican taunts that Obama hadn't followed through on his ill-considered campaign pledge to put health care negotiations on C-SPAN. (That's not the way real negotiations get done, and Obama, new to national politics, probably never dreamed he'd be taken seriously. Or he spoke without thinking.)

The Republicans believe that their strategy of denying Obama legislative victories is a winning one. If the meeting on February 25 doesn't lead to a serious bill, White House aides made it clear that the President would go ahead and try to get a health care bill anyway. Somehow.

—February 9, 2010

Obama’s confident State of the Union speech

February 8, 2010

by Hendrik Hertzberg

President Obama’s first State of the Union address came at the end of the most harrowing nine days of his young Administration. On January 19th, a Republican won the Massachusetts seat that had been held for nearly half a century by Edward M. Kennedy, thereby depriving the Senate Democrats of the sixtieth vote they need to pass legislation. A headline on the Web site of the Village Voice summarized the situation tartly and smartly: “SCOTT BROWN WINS MASS. RACE, GIVING GOP 41-59 MAJORITY.” In the aftermath, as the Brookings scholar Henry J. Aaron wrote in National Journal, “the White House and many Congressional Democrats seemed almost as shattered psychologically as the Haitians were physically after their catastrophic earthquake.”

The President doesn’t do shattered, but he was plainly discombobulated. When he was asked by George Stephanopoulos about the fate of health-care reform, he shilly-shallied. “The Senate certainly shouldn’t try to jam anything through until Scott Brown is seated,” he said. “People in Massachusetts spoke. He’s got to be part of that process.” He added, feebly, “I would advise that we try to move quickly to coalesce around those elements of the package that people agree on.” (Perhaps he had momentarily forgotten that it’s the Senate that’s supposed to advise, if not necessarily to consent. A President is supposed to lead.) A few days later, he proposed a three-year “freeze,” beginning in 2011, on discretionary, non-entitlement, non-national-security spending—about one-eighth of the federal budget. Aides quickly explained that the freeze would not be “across-the-board”—that funds would be shifted from ineffective programs to effective ones. Even so, just about everyone outside the Republican congressional caucus recognizes that, with unemployment at ten per cent, the near-term need is for more public spending—more stimulus, not less. The proposal had the look of a political gimmick and the smell of political fear.

By the time he glided into the House chamber on January 27th, Obama had recovered his balance, and then some. He looked and sounded like a trillion bucks—surplus, not deficit. He appeared to be in an unusually relaxed, even bouncy mood. He exuded confidence. The speech he delivered was no literary masterpiece (though by State of the Union standards it was downright Nabokovian), but it was a small triumph of tone and subtle theatrics. Despite the grandiosity of the setting—the curlicued proscenium, the massed dignitaries, the absurd aerobics of the endless standing ovations—the President managed to create a surprisingly intimate, almost conversational effect, as if the well of the House were a fireside and he was having a chat. With humor, reasonableness, and a touch of sarcasm, he invited the Republican grandees in the audience to play the role of straight man, so to speak, and they obliged: row upon row of pale, middle-aged white men, unmoving and unmoved, frowning or smirking at every Presidential request for coöperation.

The bulk of Obama’s speech was devoted, rightly, to job creation. But its most telling and important moment may have been the relatively brief section on health care, the problem that has consumed much of the Administration’s first year. He invited Republicans to suggest “a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors, and stop insurance company abuses”—knowing full well, of course, that they have no such approach. But he did not surrender, and he did not repeat his suggestion that reform be pared down to “elements” that “people” like. He explained why his plan would be “a vast improvement over the status quo” and issued this demand, framed as a challenge to the whole Congress but aimed squarely at his fellow-Democrats:

Don’t walk away from reform. Not now. Not when we are so close. Let us find a way to come together and finish the job for the American people. Let’s get it done. Let’s get it done.

So, so close. By the beginning of this year, both the House of Representatives and the Senate had passed comprehensive, broadly similar health-care bills. By mid-January, Democratic negotiators had nearly reached agreement on melding the two bills into one. All that remained was putting the finishing touches on the combined bill and, in both Houses, the formality of a final vote.

Post-Massachusetts, the Democratic caucus claims “only” fifty-nine senators out of a hundred—still the largest majority either party has held in thirty years and, as a percentage, precisely the same size as the Democrats’ majority in the House. But, thanks to the filibuster and to the great stone face of the monolithic Republican No, any new health-care bill that requires a standard floor vote in the Senate—indeed, any effort at health-care reform, however pared down, that could be interpreted as an accomplishment for Obama and his party—is out of the question. At this point, there is only one way to “get it done,” and only the Democrats can do it. That way is (a) for the Democrats of the House to ratify the Senate’s already-passed bill and (b) for the Democrats of the Senate to ratify whatever elements of the defunct compromise can qualify for action via a well-established procedure—“reconciliation” —under which legislative provisions that have more than “merely incidental” effects on government outlays or revenues cannot be filibustered. Reconciliation is arcane but effective, and thoroughly “bipartisan”: the Republicans used it to enact tax cuts for the comfortable, the heart of George W. Bush’s domestic program as surely as health-care reform is the heart of Barack Obama’s.

On Friday, President Obama went to Baltimore, where the House Republicans were having their annual retreat, and led them in what turned out to be, amazingly, a relatively civilized, relatively substantive discussion, mostly about health care. His passion for comity appears to be genuine. But so does his commitment to do everything he can, in the face of America’s increasingly dysfunctional governmental mechanisms and increasingly rancorous political culture, to bring about the kind of change he was elected to pursue. The discussion in Baltimore was pleasant. The day before, however, the Senate had taken a vote on extending the federal debt limit. All the Republicans voted no. That is to say, all of them voted for the United States to repudiate its obligations and go into default. That was not so pleasant.

If the President and the Democrats of Congress fail to enact health-care reform while they still have a real chance to do so, it’s hard to see how they will be able to do anything else. The damage to their ability to govern—the damage to the ability of the country to govern itself—will be severe. “I would remind you,” the President said Wednesday night, admonishing the members of his own party, “that we still have the largest majority in decades, and the people expect us to solve problems, not run for the hills.” The President made stirring music on Capitol Hill, but those other hills are alive with the sound of doom.

Health Care: Who Knows 'Best'?

Image via Wikipedia

By Jerome Groopman

One of the principal aims of the current health care legislation is to improve the quality of care. According to the President and his advisers, this should be done through science. The administration's stimulus package already devoted more than a billion dollars to "comparative effectiveness research," meaning, in the President's words, evaluating "what works and what doesn't" in the diagnosis and treatment of patients.

But comparative research on effectiveness is only part of the strategy to improve care. A second science has captured the imagination of policymakers in the White House: behavioral economics. This field attempts to explain pitfalls in reasoning and judgment that cause people to make apparently wrong decisions; its adherents believe in policies that protect against unsound clinical choices. But there is a schism between presidential advisers in their thinking over whether legislation should be coercive, aggressively pushing doctors and patients to do what the government defines as best, or whether it should be respectful of their own autonomy in making decisions. The President and Congress appear to be of two minds. How this difference is resolved will profoundly shape the culture of health care in America.

The field of behavioral economics is rooted in the seminal work of Amos Tversky and Daniel Kahneman begun some three decades ago. Drawing on data from their experiments on how people process information, particularly numerical data, these psychologists challenged the prevailing notion that the economic decisions we make are rational. We are, they wrote, prone to incorrectly weigh initial numbers, draw conclusions from single cases rather than a wide range of data, and integrate irrelevant information into our analysis. Such biases can lead us astray.

---

---

The infusion of behavioral economics into public policy is championed by Cass Sunstein, a respected professor of law and longtime friend of President Obama; he is now in the White House, overseeing regulatory affairs, and will have an important voice in codifying the details of any bill that is passed. In Nudge: Improving Decisions About Health, Wealth, and Happiness, Sunstein and Richard Thaler, a professor of behavioral science and economics at the University of Chicago, propose that people called "choice architects" should redesign our social structures to protect against the incompetencies of the human mind.^[1] Those who understand thinking better can make life better for us all.

Thaler and Sunstein build on behavioral economic research that reveals inertia to be a powerful element in how we act. Most people, they argue, will choose the "default option"—i.e., they will follow a particular course of action that is presented to them instead of making an effort to find an alternative or opt out. Further, they write,

These behavioral tendencies toward doing nothing will be re- inforced if the default option comes with some implicit or explicit suggestion that it represents the normal or even the recommended course of action.

Sunstein and Thaler propose to use default options as "nudges" in the service of "libertarian paternalism." For example, to promote a healthy diet among teenagers, broccoli and carrots would be presented at eye level in the cafeteria and would be easily available, while it would take considerable effort for students to locate junk food, thereby nudging them into accepting a healthier diet. But all choices should be "libertarian"—people should be free to opt out of "undesirable arrangements if they want to do so." The soft paternalistic nudge Sunstein and Thaler envisage should try "to influence choices in a way that will make choosers better off, as judged by themselves." They are very clear that nudges are not mandates, and that behavior should not be forcefully directed by changing economic incentives. Your doctor should not be paid less if she follows a course of treatment that she can defend as reasonable, even if she deviates from officially issued guidelines. To prevent policy planners from going down the slippery slope of coercion, there should, in Sunstein's view, be safety rails. Whatever the proposal put forward, he has written, people must retain "freedom of choice" and be able to oppose the more objectionable kinds of government intervention.

Such freedom of choice, however, is not supported by a second key Obama adviser, Peter Orszag, director of the Office of Management and Budget. In June 2008, testifying before Max Baucus's Senate Finance Committee, Orszag—at the time director of the Congressional Budget Office—expressed his belief that behavioral economics should seriously guide the delivery of health care. In subsequent testimony, he made it clear that he does not trust doctors and health administrators to do what is "best" if they do no more than consider treatment guidelines as the "default setting," the procedure that would generally be followed, but with freedom to opt out. Rather, he said,

To alter providers' behavior, it is probably necessary to combine comparative effectiveness research with aggressive promulgation of standards and changes in financial and other incentives. [Emphasis added.]

The word "probably" is gone in the Senate health care bill. Doctors and hospitals that follow "best practices," as defined by government-approved standards, are to receive more money and favorable public assessments. Those who deviate from federal standards would suffer financial loss and would be designated as providers of poor care. In contrast, the House bill has explicit language repudiating such coercive measures and protecting the autonomy of the decisions of doctors and patients.^[2]

On June 24, 2009, when President Obama convened a meeting on health care at the White House, Diane Sawyer of ABC News asked him whether federally designated "best practices" would be mandated or simply suggested. That is, would he recommend Orszag's shove or Sunstein's nudge?

Obama: ...Let's study and figure out what works and what doesn't. And let's encourage doctors and patients to get what works. Let's discourage what doesn't. Let's make sure that our payment incentives allow doctors to do the right thing. Because sometimes our payment incentives don't allow them to do the right things. And if we do that, then I'm confident that we can drive down costs significantly.

Sawyer: Will it just be encouragement? Or will there be a board making Solomonic decisions... about best practices?

Obama: What I've suggested is that we have a commission... made up of doctors, made up of experts, that helps set best practices.

Sawyer: By law?

Obama: ...If we know what those best practices are, then I'm confident that doctors are going to want to engage in best practices. But I'm also confident patients are going insist on it.... In some cases, people just don't know what the best practices are. And certain cultures build up. And we can change those cultures, but it's going to require some work.

Sawyer: But a lot of people... say..."I'm very concerned that there's going be a reduction in treatment someplace in all of this." And the question is if there is a board that is recommending, that's one thing. If there is a board that is dictating through cost or through some other instruction, that's another thing. Will it have the weight of law? Will it have the weight of regulations?

Obama: ...I don't think that there's anybody who would argue for us continuing to pay for things that don't make us feel better. That doesn't make any sense. [Yet] that's the reason why, in America, we typically pay 50 percent more for our health care than other advanced countries that actually have better health care outcomes.

Still, the President appears not to be entirely in Orszag's camp. He has repeatedly deflected accusations of a "government takeover of health care" by asserting that no federal bureaucrat will come between the doctor and patient in clinical decision-making. The President has also repeatedly told physicians that reform would sustain them as healers, not make them into bean counters and paper pushers. In an interview on NPR two days before passage of the Senate bill, the President said that changes in how doctors and patients think about health care should come from giving them the "best information possible" and did not invoke the coercive measures favored by Orszag.

How do we reconcile this apparent difference between Sunstein and Orszag? The President contends that sound policies are built on data, but which data? Here the evidence is strongly in favor of Sunstein and his insistence on the need for freedom of choice and retaining the ability to oppose objectionable forms of government intervention. Over the past decade, federal "choice architects"—i.e., doctors and other experts acting for the government and making use of research on comparative effectiveness—have repeatedly identified "best practices," only to have them shown to be ineffective or even deleterious.

For example, Medicare specified that it was a "best practice" to tightly control blood sugar levels in critically ill patients in intensive care. That measure of quality was not only shown to be wrong but resulted in a higher likelihood of death when compared to measures allowing a more flexible treatment and higher blood sugar. Similarly, government officials directed that normal blood sugar levels should be maintained in ambulatory diabetics with cardiovascular disease. Studies in Canada and the United States showed that this "best practice" was misconceived. There were more deaths when doctors obeyed this rule than when patients received what the government had designated as subpar treatment (in which sugar levels were allowed to vary).

There are many other such failures of allegedly "best" practices. An analysis of Medicare's recommendations for hip and knee replacement by orthopedic surgeons revealed that conforming to, or deviating from, the "quality metrics"—i.e., the supposedly superior procedure—had no effect on the rate of complications from the operation or on the clinical outcomes of cases treated. A study of patients with congestive heart failure concluded that most of the measures prescribed by federal authorities for "quality" treatment had no major impact on the disorder. In another example, government standards required that patients with renal failure who were on dialysis had to receive statin drugs to prevent stroke and heart attack; a major study published last year disproved the value of this treatment.

Other "quality measures" recommended by the government were carried out in community health centers to improve the condition of patients with asthma, diabetes, and hypertension. The conclusion of subsequent research was that there was, as a result, no change in outcome for any of these three disorders. Finally, Medicare, following the recommendations of an expert panel, specified that all patients with pneumonia must receive antibiotics within four hours of arrival at the emergency room. Many doctors strongly disagreed with such a rigid rule, pointing out that an accurate diagnosis cannot be made so quickly, and the requirement to treat within four hours was not based on convincing evidence. But the government went ahead, and the behavior of physicians was altered by the new default setting—for the worse. Many cases of heart failure or asthma, where the chest X-ray can resemble a pulmonary infection, were wrongly diagnosed as pneumonia; the misdiagnosed patients were given high doses of antibiotics, resulting in some cases of antibiotic-induced colitis. The "quality measure" was ultimately rescinded.^[3]

What may account for the repeated failures of expert panels to identify and validate "best practices"? In large part, the panels made a conceptual error. They did not distinguish between medical practices that can be standardized and not significantly altered by the condition of the individual patient, and those that must be adapted to a particular person. For instance, inserting an intravenous catheter into a blood vessel involves essentially the same set of procedures for everyone in order to assure that the catheter does not cause infection. Here is an example of how studies of comparative effectiveness can readily prove the value of an approach by which "one size fits all." Moreover, there is no violation of autonomy in adopting "aggressive" measures of this kind to assure patient safety.

But once we depart from such mechanical procedures and impose a single "best practice" on a complex malady, our treatment is too often inadequate. Ironically, the failure of experts to recognize when they overreach can be explained by insights from behavioral economics. I know, because I contributed to a misconceived "best practice."

My early research involved so-called growth factors: proteins that stimulate the bone marrow to produce blood cells. I participated in the development of erythropoietin, the red cell growth factor, as a treatment for anemic cancer patients. Erythropoietin appeared to reduce the anemia, lessening the frequency of transfusion. With other experts, I performed a "meta-analysis," i.e., a study bringing together data from multiple clinical trials. We concluded that erythropoietin significantly improved the health of cancer patients and we recommended it to them as their default option. But our analysis and guidelines were wrong. The benefits ultimately were shown to be minor and the risks of treatment sometimes severe, including stroke and heart attack.^[4]

After this failure, I came to realize that I had suffered from a "Pygmalion complex." I had fallen in love with my own work and analytical skills. In behavioral economics, this is called "overconfidence bias," by which we overestimate our ability to analyze information, make accurate estimates, and project outcomes. Experts become intoxicated with their past success and fail to be sufficiently self-critical.

A second flaw in formulating "best practices" is also explained by behavioral economics—"confirmation bias." This is the tendency to discount contradictory data, staying wed to assumptions despite conflicting evidence. Inconsistent findings are rationalized as being "outliers." There were, indeed, other experts who questioned our anemia analysis, arguing that we had hastily come to a conclusion, neglecting findings that conflicted with our position. Those skeptics were right.^[5]

Yet a third powerful bias identified in behavioral economics can plague expert panels: this is the "focusing illusion," which occurs when, basing our predictions on a single change in the status quo, we mistakenly forecast dramatic effects on an overall condition. "If only I moved from the Midwest to sunny California, I would be so much happier" is a classical statement of a focusing illusion, proven to be such by studies of people who have actually moved across the country. Another such illusion was the prescription of estrogen as the single remedy to restore feminine youth and prevent heart disease, dementia, and other complications of the complex biology of aging.^[6] Such claims turned out to be seriously flawed.

There is a growing awareness among researchers, including advocates of quality measures, that past efforts to standardize and broadly mandate "best practices" were scientifically misconceived. Dr. Carolyn Clancy of the Agency for Healthcare Research and Quality, the federal body that establishes quality measures, acknowledged that clinical trials yield averages that often do not reflect the "real world" of individual patients, particularly those with multiple medical conditions. Nor do current findings on best practices take into account changes in an illness as it evolves over time. Tight control of blood sugar may help some diabetics, but not others. Such control may be prudent at one stage of the malady and not at a later stage. For years, the standards for treatment of the disease were blind to this clinical reality.^[7]

Orszag's mandates not only ignore such conceptual concerns but also raise ethical dilemmas. Should physicians and hospitals receive refunds after they have suffered financial penalties for deviating from mistaken quality measures? Should public apologies be made for incorrect reports from government sources informing the public that certain doctors or hospitals were not providing "quality care" when they actually were? Should a physician who is skeptical about a mandated "best practice" inform the patient of his opinion? To aggressively implement a presumed but still unproven "best practice" is essentially a clinical experiment. Should the patient sign an informed consent document before he receives the treatment? Should every patient who is treated by a questionable "best practice" be told that there are credible experts who disagree with the guideline?

But even when there are no coercive measures, revising or reversing the default option requires a more complicated procedure than the one described by the President at the White House meeting. In November, the United States Preventive Services Task Force, reversing a long-standing guideline, recommended that women between the ages of forty and forty-nine do not need to have routine mammograms. To arrive at this conclusion, researchers made both a meta-analysis and computer models of data from seven clinical trials. The task force found that routine mammograms result in a 15 percent reduction in the relative risk of death from breast cancer for women in the forty to forty-nine age group, a similar level of benefit as in earlier analyses. For women in their forties, this means one life is saved for every 1,904 women screened. For older women in their fifties, one life is saved for every 1,359 women screened.^[8]

If these estimates are correct, then how many lives might be saved in the United States for each age group if every woman received a mammogram? The 2008 US Census estimates the number of women between forty and forty-nine at 22.3 million. So if mammography were available to all these women, nearly 12,000 deaths could be potentially averted during these ten years in their lives. As for the 20.5 million women in their fifties, some 15,000 deaths could potentially be averted.

What are the risks of mammography for women in their forties? The task force estimated a higher rate of false positive findings in mammograms in women in their forties compared to older women. This translates into increased anxiety when women are told that there may be a cancer and there is not. A false positive reading may also result in a woman having a biopsy. For every case of invasive breast cancer in a young woman diagnosed by mammography, five women with benign findings will have biopsies. In addition, there are potential risks of radiation from the mammogram itself, although no one really knows how significant these are. Then there is an unanswered question in the biology of breast cancer: Which tumors are indolent and which are aggressive? We lack the molecular tools to distinguish between slow- and fast-growing cancers. Some slow-growing ones detected in young women might be treated later in life without any disadvantage in the rate of survival. But aggressive breast cancers in young women are notoriously difficult to treat and frequently result in death. And as with essentially all screening tests in a population, the majority of women receiving mammograms do not have any disorder.

These, roughly, are the statistics and state of the science with regard to breast cancer. How do we weigh the evidence and apply it to individuals and to society at large? Setting the default option that doctors will present to patients requires us to make value judgments. Dr. Otis Brawley of the American Cancer Society, an oncologist who worked for decades at the National Cancer Institute, is well versed in preventive care; he disagrees with the new default setting, based on findings that mammograms save lives. (Brawley also happens to be an African-American and has long been concerned about the meager access among minority and poor groups to potentially lifesaving screenings.)

Dr. Diana Petitti, a professor of bioinformatics at Arizona State University and vice-chair of the task force, appeared with Brawley on November 17, 2009, on the PBS NewsHour. She had no disagreement with him about what the studies show, and emphasized that the task force did not say that women in their forties should not get mammograms, only that they were no longer routinely recommended since the benefit to patients did not clearly outweigh the risks. Cost considerations were not part of the task force's deliberations.

Other supporters of the new recommendations took a less temperate view. A statistician who developed computer models for the task force told The New York Times that "this decision is a no-brainer."^[9] It did not appear to be so clear to Melissa Block of NPR when she interviewed an internist who agreed with the task force. The doctor said that stopping routine mammography for young women would spare them anxiety, distress, and unnecessary biopsies. Block replied, "I've heard this before.... When people say, you know, there's unnecessary anxiety and false positives and fear and worry." That, she said, is "a very patronizing approach to take toward women's health.... Women may very well be willing to assume those harms if it means that they may be diagnosed earlier." The internist replied that each woman should talk with her doctor and figure out what is best.^[10] Sunstein's Nudge coauthor, the behavioral economist Richard Thaler, wrote a thoughtful analysis of the pros and cons of mammography in The New York Times and concluded that "one can make a good case that we don't want the government making these choices" for us.^[11]

Two days after the task force recommendations were released, Health and Human Services Secretary Kathleen Sebelius put some distance between the Obama administration and the task force's conclusions, saying:

My message to women is simple. Mammograms have always been an important life-saving tool in the fight against breast cancer and they still are today. Keep doing what you have been doing for years....

Dr. Petitti later appeared before Congress to apologize for any "confusion" caused by the task force report. Petitti was not recanting a scientific truth. She correctly described the new recommendations as "qualitative." That is, they were offered as value judgments that could be modified or revised; and the political process offers one way of doing so. As Sunstein has written, if default options embody standards that many people judge as not better for themselves, those standards can be changed.

Shortly after the new mammography guidelines were announced, an expert panel of obstetricians and gynecologists recommended that teenage girls no longer have routine pap smears for cervical cancer.^[12] The incidence of deadly cervical cancer among teens is at most one in a million and screening does not appear to save that one life. When false positive results from screenings are followed by cervical surgery, the risk may be injury that can predispose a young woman to later premature labor. There was no public uproar following this changed default setting for many women. It was consistent with how most people value the benefit of lives saved versus risks incurred. This is the reality of "comparative effectiveness" research. It is not simply a matter of "what works and what doesn't." Nor will patients always "insist" on being treated according to what experts define as "best practice." They should be aware that there are numerous companies, some of them "not for profit," issuing standards for treatment that are congenial to the insurance industry but are often open to the kinds of counterevidence I have described here.

What of the President's statement that doctors will want to engage in federally approved "best practices"? The American College of Physicians, composed of internists, agreed with the task force conclusions about mammography. The American Society of Clinical Oncology, representing oncologists, did not. I am a member of both professional organizations. What do I do? As a physician who has cared for numerous young women with breast cancer, many dying an untimely death, my bias was that the dangers of mammograms do not outweigh the reduction in mortality. Notably, the oncologists who head the breast cancer programs at Minnesota's Mayo Clinic and Utah's Intermountain Health—described by President Obama as pinnacles of quality care using guidelines—also disagreed with the task force.

Such challenges to "best practice" do not imply that doctors should stand alone against received opinion. Most physicians seek data and views on treatments from peers and, as needed, specialists, and then present information and opinion to patients who ultimately decide.

While costs were not part of the task force calculations, they prominently entered the national debate on them. Dr. Robert Truog of Boston Children's Hospital allowed that mammography saves lives, but asked if it is "cost effective."^[13] That is, should policy planners set a price on saving those young women?

Cost-effectiveness is going to be a hard sell to the American public, not only because of the great value placed on each life in the Judeo-Christian tradition, but because the federal government has devoted many hundreds of billions of dollars to bail out Wall Street. To perform mammograms for all American women in their forties costs some $3 billion a year, a pittance compared to the money put into the bank rescue. The Wall Street debacle also made many Americans suspicious of "quants," the math whizzes who developed computer models that in theory accurately assessed value in complex monetary instruments but in fact nearly brought down the worldwide financial system. When a medical statistician says that imposing a limit on mammography is a "no-brainer," people may recall George Tenet's claim that the case for invading Iraq was a "slam-dunk."

At the White House gathering, the President portrayed comparative effectiveness as equivalent to cost- effectiveness, noting that other countries spend half of what we do by only paying for "what works." This contention is not supported by evidence. Theodore Marmor, a professor of health care policy at Yale, writes in Fads, Fallacies and Foolishness in Medical Care Management and Policy that movements for "quality improvement" in Britain have failed to reduce expenditures.^[14] Marmor, with Jonathan Oberlander, a professor at the University of North Carolina, has written in these pages that the President has offered up rosy scenarios to avoid the harsh truth that there is no "painless cost control."^[15] Lower spending in countries like France and Germany is accounted for not by comparative effectiveness studies but by lower costs of treatment attained through their systems of medical care and by reduced medical budgets. In Europe, prescription drugs cost between 50 and 60 percent of what they do in the US, and doctor's salaries are lower. (Insurance premiums also are tightly constrained.) France and Germany have good records in health care, but in Great Britain, where costs are strictly controlled by the National Health Service, with rationing of expensive treatments, outcomes for many cancers are among the worst in Europe.^[16]

The care of patients is complex, and choices about treatments involve difficult tradeoffs. That the uncertainties can be erased by mandates from experts is a misconceived panacea, a "focusing illusion." If a bill passes, Cass Sunstein will be central in drawing up the regulations that carry out its principles. Let's hope his thinking prevails.

—January 14, 2010

Notes

^[1]Yale University Press, 2008; See the review in these pages by John Cassidy, "Economics: Which Way for Obama?," June 12, 2008.

^[2]On June 16, 2008, at the Health Reform Summit of the Senate Finance Committee, Orszag explicitly invoked behavioral economics to explain some of the deficiencies in American health care and as the basis for legislative interventions that would remedy rapidly escalating costs and gaps in quality.

On August 7, 2008, addressing the Retirement Research Consortium in Washington, D.C., Orszag presented "Behavioral Economics: Lessons from Retirement Research for Health Care and Beyond." Here, he states the likely need for aggressive measures. The Senate Finance Committee, under Max Baucus, was widely reported to have worked closely with the White House, and many of Orszag's proposals are prominent in the bill that Majority Leader Harry Reid brought to the floor. See Senate Bill HR 3590, Title III—Improving the Quality and Efficiency of Health Care.

The House rejected many of the ideas from the President's advisers in favor of safeguards on patient–physician autonomy, causing Rahm Emanuel, the White House chief of staff, to quip that politics trumps "ideal" plans made in the shade of the "Aspen Institute." See Sheryl Gay Stolberg, "Democrats Raise Alarms over Health Bill Costs," The New York Times, November 9, 2009. Explicit language in the House bill is intended to safeguard patient–physician autonomy. See House Bill HR 3962, Title IV—Quality; Subtitle A—Comparative Effectiveness Research.

^[3]These results, respectively, come from the NICE-SUGAR Study Investigators, "Intensive versus Conventional Glucose Control in Critically Ill Patients," The New England Journal of Medicine, March 26, 2009; Silvio E. Inzucchi and Mark D. Siegel, "Glucose Control in the ICU—How Tight Is Too Tight?," The New England Journal of Medicine, March 26, 2009; the Action to Control Cardiovascular Risk in Diabetes Study Group, "Effects of Intensive Glucose Lowering in Type 2 Diabetes," The New England Journal of Medicine, June 12, 2008; the ADVANCE Collaborative Group, "Intensive Blood Glucose Control and Vascular Outcomes in Patients with Type 2 Diabetes," The New England Journal of Medicine, June 12, 2008; Robert G. Dluhy and Graham T. McMahon, "Intensive Glycemic Control in the ACCORD and ADVANCE Trials," The New England Journal of Medicine, June 12, 2008; Gregg C. Fonarow et al., "Association Between Performance Measures and Clinical Outcomes for Patients Hospitalized with Heart Failure," The Journal of the American Medical Association, January 3, 2007; Bengt C. Fellström et al., for the AURORA Study Group, "Rosuvastatin and Cardiovascular Events in Patients Undergoing Hemodialysis," The New England Journal of Medicine, April 2, 2009; Bruce E. Landon et al., "Improving the Management of Chronic Disease at Community Health Center," The New England Journal of Medicine, March 1, 2007; Rodney A. Hayward, "Performance Measurement in Search of a Path," The New England Journal of Medicine, March 1, 2007; Robert M. Wachter et al., "Public Reporting of Antibiotic Timing in Patients with Pneumonia: Lessons from a Flawed Performance Measures," Annals of Internal Medicine, July 1, 2008.

^[4]The clinical development of other growth factors, like G-CSF for a low white blood cell count, fared better. G-CSF is a valuable treatment for many cancer patients, but, of course, not all.

^[5]Contradictory evidence reverses "best practices" so frequently that within one year 15 percent must be changed, within two years, 23 percent are reversed, and at 5.5 years, half are incorrect. See Kaveh G. Shojania et al., "How Quickly Do Systematic Reviews Go Out of Date? A Survival Analysis," Annals of Internal Medicine, August 21, 2007.

^[6]Focusing illusions are wonderfully illuminated by Daniel Gilbert, Stumbling on Happiness (Knopf, 2006). Also see the role of marketing in fostering the illusion: Natasha Singer and Duff Wilson, "Menopause, as Brought to You by Big Pharma," The New York Times, December 13, 2009. See also David A. Schkade and Daniel Kahneman, "Does Living in California Make People Happy? A Focusing Illusion in Judgments of Life Satisfaction," Psychological Science, September 1998.

^[7]Dr. Clancy seeks new statistical methods to analyze heterogeneous groups of "real world" patients, so treatment guidelines become "personalized," delivering "the right treatment to the right patient at the right time." (See Patrick H. Conway and Carolyn Clancy, "Comparative-Effectiveness Research —Implications of the Federal Coordinating Council's Report," The New England Journal of Medicine, July 23, 2009; Harold C. Sox and Sheldon Greenfield, "Comparative Effectiveness Research: A Report From the Institute of Medicine," Annals of Internal Medicine, August 4, 2009.) This is a laudable goal and deeply attractive. It is more likely to come from basic science that classifies patients based on their genetic characteristics rather than statistics. Past attempts at observing groups of "real world" patients have often generated conclusions that were flawed, mistaking correlation for causation. A valiant attempt to apply research on comparative effectiveness to prostate cancer treatment options came up against similar hurdles. See Jenny Marder, "A User's Guide to Cancer Treatment," Science, November 27, 2009.

^[8]US Preventive Services Task Force, "Screening for Breast Cancer: US Preventive Services Task Force Recommendation Statement," Annals of Internal Medicine, November 17, 2009; Heidi D. Nelson et al., "Screening for Breast Cancer: An Update for the US Preventive Services Task Force," Annals of Internal Medicine, November 17, 2009; Jeanne S. Mandelblatt et al. for the Breast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network (CISNET), "Effects of Mammography Screening Under Different Screening Schedules: Model Estimates of Potential Benefits and Harms, Annals of Internal Medicine, November 17, 2009.

^[9]Gina Kolata, "In Reversal, Panel Urges Mammograms at 50, not 40," The New York Times, November 17, 2009. A detailed summation of the controversy is found in The Cancer Letter, November 20 and December 4, 2009.

^[10]National Public Radio, All Things Considered, November 16, 2009.

^[11]Richard H. Thaler, "Gauging the Odds (and the Costs) in Health Screening," The New York Times, December 20, 2009.

^[12]acog Practice Bulletin, "Clinical Management Guidelines for Obstetrician-Gynecologists," Number 109, Obstetrics & Gynecology, December 2009; Denise Grady, "Guidelines Push Back Age for Cervical Cancer Tests," The New York Times, November 20, 2009.

^[13]Robert D. Truog, "Screening Mammography and the 'R' Word," The New England Journal of Medicine, December 24, 2009.

^[14]World Scientific, 2007.

^[15]"Health Reform: The Fateful Moment," The New York Review, August 13, 2009.

^[16]Theodore Marmor, Jonathan Oberlander, and Joseph White, "The Obama Administration's Options for Health Care Cost Control: Hope versus Reality," Annals of Internal Medicine, April 7, 2009; Donald M. Berwick, "Measuring Physicians' Quality and Performance, The Journal of the American Medical Association, December 9, 2009. A layman's journey seeking care abroad is described in the lively book by T.R. Reid. The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care (Penguin, 2009). Concerning the uproar in Britain about poor cancer outcomes, see Nick Triggle, "NHS Must Get Better at Early Cancer Diagnosis," BBC News, November 30, 2009; Rebecca Smith, "Cancer Care on the NHS Falls Behind the Rest of Europe," The Daily Telegraph, November 30, 2009; NHS Department of Health, "Cancer Reform Strategy: Achieving Local Implementation—Second Annual Report," December 1, 2009.