More Central Planning: The Failed Panacea for Health Care Reform

A rebuttal to The New Republic's latest prescription for health care reform

Offering proposals to fix the American health care system has lately become a national pastime. In the June 9th issue of The New Republic, bioethicist Daniel Callahan and surgeon Sherwin Nuland enter the fray, prescribing massive doses of a familar and already failed nostrum: top-down central planning.

Callahan is the president emeritus of the Hastings Center bioethics think tank and author of many books including False Hopes: Why America's Quest for Perfect Health Is a Recipe for Failure, and Nuland is a retired clinical professor of surgery at Yale University and also a Hastings Center fellow. The two assert that the dire situation in which we find ourselves is the result of several mistaken assumptions: (1) “that medical advances are essentially unlimited" (2) "that none of the major lethal diseases is in theory incurable" and (3) "that progress is economically affordable if well managed.”

Callahan and Nuland boldly (and pessimistically) declare that at the heart of our dysfunctional system is the fact that are “no imminent, much less foreseeable cures for the most common and most lethal diseases.” Yet good news abounds: In May, the Centers for Disease Control and Prevention announced that average U.S. life expectancy has risen to an all time high of 78.2 years. In fact, age-adjusted death rates in the United States show that the risk of mortality at any given age have been declining substantially. In 1950, the death rate was 1,446 per 100,000, falling to 1,039 per 100,000 in 1980 and further to 741 per 100,000 in 2009. Age-adjusted rates show that, despite the fact that the U.S. population has been aging over the past half-century, the risk of mortality has actually fallen by half. 

The three biggest killers are diseases of the heart, cancer, and strokes, which account for nearly 60 percent of deaths in 2009. In 1950, 1980, and 2009, the death rates for heart disease were 587, 412, and 180 per 100,000 respectively. The cancer death rates in those same years were 194, 208, and 174 per 100,000. The rate death from strokes were 181, 96, and 39 per 100,000. (A good bit of the cancer death rate increase from 1950 to 1980 was the result of increased tobacco smoking. In 1965, 42 percent of U.S. adults smoked. Just around 20 percent do now.)

Americans still do die of infectious diseases, but nothing like they did in the past when the death rate for tuberculosis in 1900 was 194 per 100,000, which fell to 46 per 100,000 in 1940. The current TB death rate is 0.2 per 100,000, and the rate of tuberculosis infection fell to an all-time low in the U.S. of 3.6 per 100,000 last year. Even the U.S. death rate from HIV infections has fallen from 10.2 per 100,000 in 1990 to 3.7 in 2007.

Modern medicine cannot take all the credit for these declines in age-adjusted mortality. A recent study suggests that declines in risk factors such as smoking reduced heart disease rates more than medical interventions. Nevertheless, medical innovations have helped.

Cancer has been a much tougher nut to crack. The latest data shows that “overall cancer incidence rates decreased by approximately 1 percent per year” and that cancer mortality rates have been falling even faster at around 1.5 percent per year. It is good news that modern medicine has increased the five-year survival rates of cancer patients from 50 percent in the 1970s to 66 percent today.

As impressive as it is, all this good news doesn't satisfy Callahan and Nuland, who preempt such arguments by noting that “There are many ways of responding to this generally pessimistic reading of medical innovation in recent years. The most common is simply to note all the progress that has been made: useful new drugs, helpful new devices and technologies, decreased disability, better ways of controlling pain, and so on.”

Instead, they focus on the negatives. And they aren't completely wrong to do so. Even as we live longer, we may be less healthy. Callahan and Nuland cite recent research by University of Southern California gerontologists Eileen M. Crimmins and Hiram Beltrán-Sánchez which finds no evidence for the compression of morbidity, i.e., the idea that people could be living longer healthier lives and dying after a short fast illness. The concern is that while we may live longer, we also suffer a longer period of disability before we shuffle off this mortal coil.

The analysis by Crimmins and Beltrán-Sánchez disturbingly finds that in 1998, a 20-year old male could expect to live another 45 years free of cardiovascular disease, cancer, or diabetes. They calculate a 20-year old male in 2006 could expect only 43.8 years free of one of those conditions. The numbers were similar for 20-year-old women whose expected years of life without serious disease fell from 49.2 years to 48 years. What’s happening? The researchers suggest “the growing problem of lifelong obesity and increases in hypertension and high cholesterol among cohorts reaching old age are a sign that health may not be improving with each generation.” Nevertheless, should be noted that Crimmins and Beltrán-Sánchez calculate that 20-year olds in 2006 can expect to live about a year longer than those who turned 20 in 1998.

In fact, University of Pennsylvania demographers Samuel Preston and Andrew Stokes estimate that higher obesity rates reduce U.S. life expectancy at age 50 by about a year and a half for women, by nearly two years for men, explaining a good bit of the difference between U.S. life expectancy rates and those of other developed countries.

We see a record of solid progress, but also some serious hurdles to overcome. Are Callahan and Nuland right to suggest that we are coming to the end of our therapeutic rope? I think not. The two men are correct that stem cell therapies and new treatments based on genomic science have been oversold. Nevertheless, the next biomedical revolution is just getting started. 

Just this week, hints of how the future will unfold were reported by leading journals including a much more effective new treatments for advanced melanoma, and a new preventative drug for breast cancer. Last year saw the development of a vaccine to treat prostate cancer. A new study recently found that retroviral therapies dramatically reduce the transmission of HIV and work continues on developing a vaccine against HIV. As antibiotic resistant strains of microbes develop, researchers are looking for new ways to target them and new ways to disarm them. Further down the road, RNAi (ribonucleic acid interference) might be used to treat heart failure, and stem cells to repair broken spinal cords. Successful treatments for obesity would shift the prospects for increased health in old age.

But Callahan and Nuland may grant that such treatments could be developed, and still remain convinced that something will break in our bodies in any case, resulting in (expensive) disease, disability, and inevitably death. The reply to their objection is clear: The only way to stay healthy is to prevent aging. Luckily, out on the horizon are possible therapies to do even that, including sirtuins and compounds that extend the ends of chromosomes, called telomeres. Biology is extremely complicated, but there seems to be no a priori reason why an engineering approach using increasingly sophisticated bioinformatics and experimental techniques cannot figure out how to repair diseased and damaged tissues and organs.

Based on the foregoing examples, the assumption that medical advances are unlimited and that none of the major diseases are in theory incurable seem reasonable to me. But what about the third assumption that Callahan and Nuland dismiss as implausible: that medical progress is economically affordable if well managed?

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  • ||

    You gotta love an "ethicist" arguing for the negation of autonomy and choice, and the imposition of a coercive system.

  • rather||

    Perhaps our "ethicist" recognizes that health care is a right. Sounds ethical to me

  • sarcasmic||

    Health care consists of goods and services provided by medical professionals.

    By saying health care is a right, you are saying you have a right to the property and labor of others based upon their chosen profession.

  • Jefferson Davis||

    Rather is correct. We also have a right to slave labor.

  • The Derider||

    By saying voting is a right, you are saying you have a right to the property and labor of pollsters, based upon their chosen profession.

  • cynical||

    Voting isn't an inherent right, it's a political one, a restriction on the ways that a government can be constructed. A government cannot be assumed, so political rights do not necessarily lead to slave labor.

  • ||

    so a right = less choice? Hurray!

  • kinnath||

    George ought to help

  • Hemlock||

    Prove health care is a right. Show your work.

  • ||

    If health care is a right, how can a government central planning board deny it to me?

  • DLM||

    If health care is a right, it's not unreasonable to extend that and say unlimited health care is a right. Otherwise, you are in the position of saying only a limited amount of health care is a right, then you need to define what the limit is.

  • cynical||

    That's because you're an unfortunate combination of stupid and selfish.

  • OO||

    the military/medical/industrial complex is powerful

  • ||

    Ron Bailey was for the individual mandate back in the day.

    http://reason.com/archives/200.....health-ins

    http://reason.com/archives/200.....urance-now

    Repent, Beetle, and I will surely resume loving you.

  • ||

    deified: It was always a second best alternative. See my explanation at "Center for American Progress and the New Republic Endorse Totally Private BaileyCare Plan."

  • x,y||

    Bailey also voted for Obama. He has not, to my knowledge, acknowledged that as a big mistake. His (uncritical) rationale at the time was that the Republicans need to be punished, and punished hard. Apparently voting for Obama was the only way to do that. Not voting or voting third party aren't options in Ronald Bailey World.

    Will he come down to the streets Omar Little style to defend his indefensible vote this time?

    I predict crickets.

  • DLM||

    His (uncritical) rationale at the time was that the Republicans need to be punished, and punished hard.

    What I don't understand is why the rest of us had to be punished, too.

  • ||

    Just for the record, Bailey has publicly said he was wrong on big issues before--why he feels it necessary to explain to the especially slow that as a policy analyst, his job isn't to analyze policy solely within the context of a libertarian utopia? Is beyond me.

    My guess is that he's just magnanimous.

    See, there's this thing called the "real world". And if our stupid president insists on implementing an individual mandate--despite Bailey's recommendations to the contrary? That doesn't mean libertarian policy analysts like Bailey should relegate themselves to only working in libertarian fantasy land.

    There are different ways to implement stupid policies--policies that Bailey was against--and some of them are more libertarian than others!

    Why should Bailey excuse himself from commenting on better and worse ways to implement the individual mandate--because Obama is initiating one?!

    That would be retarded. We do not live in a libertarian utopia. We haven't had a libertarian president since before FDR. Is Bailey allowed to talk about any policies of any president in your world--unless he or she is a libertarian?

    I don't think we should have an individual mandate--but if we're gonna have one anyway, here's what I think we should do...

    Why is that so hard to understand?!

  • ||

    "Bailey also voted for Obama."

    So what?

    Was he so supposed to be prescient?

    If he knew what he knew now...?

    Is living in a fantasy world, where the future is completely foreseeable--if only you look through the lens of partisan politics?!

    You know what sucks the most about Obama?

    He's just like George W. Bush.

    So maybe Bailey was looking to repudiate the Bush Administration on its stupid wars and violations of our constitutional rights. ...and if that didn't work out the way he hoped?

    So what.

    Here's a clue for the best definition of a libertarian I've ever seen: a real libertarian? Is someone who doesn't think politicians are the solution to our problems.

    If you think voting for one politician over another is the solution to our problems? Then wear that shoe, Buddy Roe!

  • ||

    "If you think voting for one politician over another is the solution to our problems? Then wear that shoe, Buddy Roe!"

    Don't try to make libertarians (like Bailey) take off theirs.

  • Bill||

    Ron,

    I don't mean to quibble (ok, maybe I do), but turn on the spell-checker and grammar checker. Lots of typos and missing words in this one. Distracting.

  • rather||

    If we had public health care, he'd make less mistakes;-)

  • Arcaster||

    If we had public health care, he's still be waiting to see a doctor. Do you intentionally ignore reality, or are you really that ignorant?

  • ||

    Do you intentionally ignore reality, or are you really that ignorant?

    This is a rhetorical question, right?

  • ||

    Uh, that's FEWER mistakes. Unless you meant he would make have made smaller mistakes, then you should have said "LESSER" mistakes. If you're going to nit pick, start with your own nits.

  • rather||

    Consumers looking out for their own health and insurance needs would be vigilant about the costs and benefits of treatments, ensuring that medical progress remains economically affordable.

    I hear all you have to do is click your heels together and you can control pricing!

  • ||

    If only we could click our heels together and you'd disappear.

  • OO||

    oh noes rather. dont make libtoids acknowledge "free-market" collusion & anti-competititve practices.

  • Citizen Nothing||

    Fuck, yes! It's free-market collusion and anti-competitive practices that are the root of all our problems!
    Why the fuck didn't I see that before now?
    WHY THE FUCK DIDN'T I SEE THAT BEFORE NOW?
    Praise Jesus! I'm healed!

  • Citizen Nothing||

    Well, I guess omniscient government should actually get the credit instead of Jesus. But you know what I mean.

  • Joe Stalin||

    Check out my tractors!

  • ||

  • rather||

    epi, stop wearing my fuck-me pumps, and get my fucking coffee

  • Concerned Citizen||

    Open a gas station and charge $10/gallon. You'll be rich in no time.

  • Citizen Nothing||

    Government-adoring types who accuse libertarians of worshiping the market are akin to Catholics who would accusing atheists of worshiping the void.
    Political "theists," if you will, just can't conceive of a politically "agnostic" system and believe libertarians must belong to a cult just like theirs, only with the wrong god.

  • ||

    +1

  • ||

    It's insights like that that keep me coming back to this site. Well said.

  • ||

    Well said.

  • OO||

    -1 since ur "free-market" god devolves into a would-be monopoly always seeking to minimize competition.

  • ||

    This is the point where I ask you to point out a monopoly that did not have government aiding it, sometimes the point of outlawing competition?

  • ||

    Should be interesting to see how all that stuff works out in the end. Wow.

    www.online-privacy.no.tc

  • Citizen Nothing||

    Wow, indeed, AnonoBot.
    Wow, indeed.

  • Dr. Dave||

    Dr. Nuland is an unfortunate example of how mastery of medicine does not ensure mastery of other fields such as economics.

    I would suggest that he do some cursory reading on the history of central planning and price controls before authoring another book on health care economics.

  • rather||

    Dr. Dave, is an example of a doctor who is in it for the money.

  • ||

    Even if that were true, don't you do what you do for the money?

    "Doin' it for the money" has led to the investments and innovations that make our middle class healthy, comfortable and large.

    If anything, we need more people "doin' it for the money". God save us all from people whose primary motivation is altruism.

  • iamtheeviltwin||

    'Doin it for the Money' is the only reason I'm working and providing a service to my customers instead of sitting on my ass at home playing video games.

  • Arcaster||

    ^ This

  • Mao, Che, Pol, etc||

    Hey, we all accomplished terrific things with our alturism!

  • Dr. Dave||

    Baseless personal attacks are no substitute for well-reasoned arguments. In fact, resorting to such attacks is an obvious sign that you have lost the argument.

    By the way, I am only advocating for the freest, highest quality and most affordable health system - a system which would greatly benefit my patients while quite possibly resulting in significantly lower compensation for me.

  • Dr. Dave||

    And - as others point out - when did making an honest living while helping others become such a bad thing? When did economic freedom become such a bad thing? Like it or not, human beings largely operate out of individual self-interest and by doing so, they (and society)ultimately prosper. Ignorance of this basic reality of human nature has only produced disaster.

  • DLM||

    Baseless personal attacks are no substitute for well-reasoned arguments.

    It kind of depends on the goal.

  • mr simple||

    in 1998, a 20-year old male could expect to live another 45 years free of cardiovascular disease, cancer, or diabetes. They calculate a 20-year old male in 2006 could expect only 43.8 years free of one of those conditions

    Clearly the only solution is government issued insurance. How can people be expected to take care of themselves?

  • ||

    Here's another plan that's worked great internationally:

    Phase I: Convince a critical mass of people that the government isn't really about to take over healthcare, control access or limit distribution.

    Phase II: Once the government has taken over healthcare--control access and limit distribution.

  • ||

    You can keep your insurance!

    P.S. No, you can't.

    "A new study by McKinsey suggests that as many as 78 million Americans could lose employer health coverage."

    http://online.wsj.com/article/.....01600.html

  • ||

    to be fair, all employer-related insurance should be removed. This is in fact the one-step solution to all health care "problems" with our system now.

    If everyone was responsible for getting their own insurance, they would do so BEFORE they came down with a condition and they would not lose it when they lose a job.

  • Concerned Citizen||

    What, like car insurance? That's just crazy talk.

  • ||

    Actually, employers should be free to offer their employees whatever they want in terms of compensation for work.

    What problems we have aren't due to employers paying employees with health insurance; they're due to various aspects of government interference in the healthcare market.

    I'd start with Medicare and Medicaid only paying for a fraction of the hospital costs their members impose on the system--forcing hospitals to gouge private insurers to make up for the difference.

    I think that's another nominee for the most widely held fallacy--and most destructive too. ...the idea that just because Medicare and Medicaid members don't have to pay for all the healthcare they consume--that means Medicare and Medicaid pay for the rest of it?

    That's baloney! Widely believed baloney.

    How would employees buying their own healthcare remedy Medicare and Medicaid only paying for a fraction of the hospital costs their members consume?

  • ||

    That's fine Ken,as long as it's taxed like any other income.I

  • ||

    and if the employer can chose the amount of coverage they will provide

  • Concerned Citizen||

    Fuck the income tax. Greatest scam ever.

  • ||

    I don't see how raising taxes on employees is a viable solution to government interference in the healthcare markets.

  • ||

    it's not raising taxes,it's treating employer paid insurance for what it is,income.Plus the companies escape matching taxes many small companies have to pay .I'm for a flat tax or and a low corp. tax,or none at all. ,but,all compensation needs to be treated the same.Ending the employer based system would make people take more control of their lives.

  • ||

    "I'm for a flat tax or and a low corp. tax,or none at all. ,but,all compensation needs to be treated the same."

    Regardless, taxing health benefits has nothing to do with curing what ails the healthcare industry.

  • ||

    "Ending the employer based system would make people take more control of their lives."

    You know what would give people the opportunity to take more control of their lives?

    Getting rid of the notion that people owe you something just because they work for a living.

    Businesses that partially pay their employees in tax free healthcare? Owe you nothing. Employees who are partially compensated in tax free healthcare?

    Owe you nothing.

  • ||

    I'm tired of the terms health care and health insurance.It was called major medical or hospitalization insurance for years.Now,people expect to pay little or nothing to to the provider and a third party picks up the bill.This drives up costs.Paying for a doctors visit is unheard of to many,maybe just a small co-pay.Then we have the old folk ,who demand their medicare at any cost to the young.Many costs need to be paid for on the spot,out of pocket

  • Concerned Citizen||

    "Now,people expect to pay little or nothing"

    So true. I worked in collections for years, and was always amazed at the collection agency accounts on credit bureaus for balances of $100 or less. When someone needs a doctor, they fucking need a doctor. But no way will they pay for it.

  • ||

    but then they'd have to pay for their doctor visits and birth control pills and viagria and ....

  • A Serious Man||

    Honest question: even in a free market system, which I am convinced would be superior to our current government-corporate healthcare cartel, what would be the incentive for doctors and other provider groups to provide services for the chronically ill at affordable prices? I know people that are born with chronic conditons that require constant medical attention.

  • kinnath||

    There is no incentive.

    A perceived moral obligation on the part of person A to help person B when person B is in time of need (refer to any major religion) does not constitute a right that person B has on getting help from person A against person A's will.

    So in a truly free society, someone fucked by the roll of the dice at birth has no legitimate expection, other than good will, to receive help from anyone.

    You can choose to be free and live in the wild or be a captive and live in a gilded cage. But whatever you choose, you cannot impose your choice on me.

  • pmains||

    In a free market, companies have an incentive to provide low cost treatments for chronic conditions because, if they do not, their competitors will.

    The sort of thinking that says, "doctors don't want to cure you because then you won't come back," assumes that medical profession operates as a cartel.

  • kinnath||

    No doubt that as long as there is a business case to be made by providing care to chronically ill, then someone will do it.

    But when serious man asks about incentives he implies that people need to be coerced into helping the chronically ill when there is not business case.

  • A Serious Man||

    No I don't believe in coercing people to act morally, I'm just wondering if the market would cover that or if it would have to be delegated to private, charitible groups.

  • kinnath||

    People either help other people because of a profit motive or good will; there aren't any other choices beyond coerced behavior.

  • ||

    If there were no care facilities in existence today I would create one and the people would quickly come. Unfortunately there are so many regulations in place now no way in hell would I attempt it. BTW I'm in the process of designing one now, for a person who has a moral desire and believes there can be a profit.

  • kinnath||

    Profit-seeking and good-will are not mutually exclusive.

  • Concerned Citizen||

    Exactly. That's why we have Lutheran Social Services, Catholic Charities, Knights of Columbus, Elks, Moose Lodge, Red Cross, and many more, to help those who need help.

  • NoVAHockey||

    most proposals include some sort of funding mechanism that is not insurance. usually it's paired with reforms of Medicaid. check out
    http://www.cato.org/pubs/handb.....111-13.pdf

  • Contrarian P||

    It's what we used to do. Most of us consider it to be an obligation, even a privilege, of being a physician to render low or no cost care to those with less ability to pay. What we dislike is being forced to do it, and particularly we dislike being legally actionable by those who demand care from us without compensation.

  • kinnath||

    It's shocking to me how few people can't see the difference between a moral obligation to help those in need and a legal obligation to help those in need under penalty of law for non-compliance.

  • kinnath||

    It's shocking to me how few people can't see the difference.....

  • cynical||

    How do you determine when moral obligations should become legal obligations?

  • ||

    It's mostly a coin flip.

    Actually, that's a joke.

    It's the difference between coercion and volition.

    Legal obligations should either entered into voluntarily, or they should be a punishment for coercion.

    Forcing other people to do things against their will should be the definition of crime. Forcing people to live up to the contracts they agree to voluntarily, on the other hand, is justice.

    It's all about coercion and volition.

  • Kroneborge||

    Overall, good article. But centeralized healthcare can and does control costs. As can clearly be shown by looking at many other socialized systems. IE rationing healthcare works.

    I'm not saying that's the best solution. But to say it can't or won't control costs isn't true. I imagine once you get those death panels going, costs will drop quickly, lol.

  • OO||

    death panels are active at the state level. ck jan brewer tossing citizens awaiting transplant off state medicare

  • DLM||

    But centeralized healthcare can and does control costs.

    It's also a question of quality of healthcare and the retardation (if that's even a word) of future medical advancements. It's simplistic to focus only on costs. A plague would control costs. (I guess I shouldn't give anyone ideas.)

  • ||

    "But to say it can't or won't control costs isn't true."

    DEMAN KURV!

    Rationing doesn't control costs.

    It keeps them lower for some people!

    Not having access to something you would have had access to is a cost.

    Empty shelves and waiting for hours in bread lines was the cost of rationing toward the end of the U.S.S.R.

    http://en.wikipedia.org/wiki/Shortage#Examples

    Rationing might keep prices down for some! But I defy anyone to prove that the unavailability of something isn't a cost.

    Not having access is the price we pay for rationing.

  • Kroneborge||

    Stop being obtuse. It's quite clear here that we are talking about actual costs paid for out of the budget, and NOT other types of economic costs.

    If a country creates a healthcare budget and stops spending after that amount, they are controlling their costs. Yes there are consequences to that. People might die for lack of treatment, or remain in pain. But it does control those costs. See for example Britian and the long waits for "elective" surgery.

    @ DLM agreed there are other considerations that make an open market solution IMO probably superior (no real hard data because no real free healthcare markets). My point was simply that aruging that socialized medicine can't control costs is false. Many other countries spend several percent less of GDP on healthcare than we do.

    Of course global medical research is financed by the profits that are made in the US.

  • ||

    "Stop being obtuse. It's quite clear here that we are talking about actual costs paid for out of the budget, and NOT other types of economic costs."

    There's nothing obtuse about pointing out that being forced to go without something is the trade off for rationing.

    What's obtuse is the suggestion that we should being forced to go without something should be ignored--because we don't have to pay for it.

  • Pandora UK||

    Stop being obtuse. It's quite clear here that we are talking about actual costs paid for out of the budget, and NOT other types of economic costs.

  • ||

    ,
    FL + V A ruled pp aca NOT const.
    tutional.
    it removes 'limits on benefits
    (treatments) one can get, but
    sets up 'cost effective panels'
    . . + web says allows
    'pvt' = corporate hmo's to charge
    any premimum (tho may make them
    pay out 80% of rev. in 'benefits'>

  • nike air force 1||

    is good

  • goallen||

    I am an aspiring architect and I am appalled

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