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Behold, a National and Rational Conversation on Health Care

By Steven Pearlstein
Wednesday, August 12, 2009

Republican strategists and their media rabble-rousers cleverly thought they could dispatch their shock troops this month and kill health reform once and for all.

Instead, they're on the verge of generating what they've been desperate to avoid -- an urgent, national, rational conversation on how to make the health-care system fairer and more affordable.

To be sure, many details of health reform are still to be ironed out. But in the end, what is likely to emerge from this conversation is a health system that looks more like what President Obama has in mind than what Republicans have been peddling these past 15 years without any visible signs of success.

At his town hall meeting Tuesday in Portsmouth, N.H., Obama reminded us of the deft political touch and mastery of policy details that won him the presidency. He and the good citizens of southern New Hampshire have set the standard against which other politicians and citizens will be judged.

Here at The Post, we have our own ongoing town hall meeting on the health reform issue -- online and in print -- that also demonstrates how it is possible to disagree about health reform without being disagreeable. In that spirit, I'd like to call attention to three columns by friends and colleagues that appeared over the past week.

Charles Krauthammer weighed in with a two-point plan for health reform that was certainly refreshing in its brevity and simplicity. Charles is not a man to be trifled with on any issue, but particularly on health care, inasmuch as he was trained as a doctor before turning to the higher calling of journalism. His diagnosis of what ails the U.S. health-care system, however, seems stubbornly incomplete.

Yes, the fear of malpractice suits causes many doctors to practice defensive medicine, but its impact on the cost of care is greatly exaggerated. Krauthammer, like many malpractice critics, relies on an article in the New England Journal of Medicine that is based primarily on a survey of doctors in Massachusetts. Subsequent studies, along with the experience of states that have capped punitive damage awards, suggest that the impact of malpractice awards on overall health spending is nowhere near the 25 percent that doctors like to claim.

That said, there are good political as well as policy reasons why malpractice reform should be part of health reform. But Charles loses me when he proposes that instead of relying on judges and juries, decisions about whether an error was made and whether a doctor should be sanctioned should be made by other doctors. These are the same professionals whose record in refusing to discipline their own is virtually unblemished.

Krauthammer's other observation is that most problems with the health-care system would be solved if people bought their health insurance on the open market rather than getting it at work, where it is subsidized by employers and federal tax breaks. It is certainly true that if we were starting from scratch, nobody today would suggest an employer-based system. But now that we have it, there is precious little evidence that either employers or workers are eager to scrap it. Nor does experience suggest that a largely unregulated market for individual insurance would provide greater choice or affordability. In fact, the evidence suggests just the opposite.

Also weighing in this week was Robert Samuelson, who takes a back seat to no American when it comes to worrying about big government and big deficits. Unlike Krauthammer, "Sam" correctly identifies fee-for-service medicine as the big culprit in the driving up health-care costs. And, like Obama, he sees the solution in bundled payments to hospitals and coordinated care networks of doctors that would take responsibility for all their patients' medical needs in return for fixed annual payments.

Samuelson's beef with Obama is that the president prefers to introduce these reforms over time, through pilot projects and open competition, instead of immediately restructuring the Medicare and Medicaid systems to incorporate these ideas. Where Sam senses the lack of courage, however, others might see the astute political judgment of a president who sees the folly of using grandma as the cutting edge of a bold national experiment aimed at redefining the doctor-patient relationship and dramatically altering the way health care is delivered.

What I liked about Gene Robinson's most recent column was its candor in reminding us that there's no way to cut the growth of medical spending without cutting the growth of medical services. But Gene too easily makes the leap from there to saying that the only way to cut back on unnecessary care is to force such decisions on doctors and their patients.

In fact, there is now a growing body of evidence that when doctors and patients are presented with solid evidence by other health professionals about what works and what doesn't, they tend to make the right medical decisions without having to be cajoled or threatened. The problem today is that, too often, the reliable evidence doesn't exist, the doctor doesn't know about it, or it isn't presented to patients in a way they can understand and digest.

What that means is that there are huge savings -- literally hundreds of billions of dollars a year -- that can be realized before we reach the point at which we have to make those gut-wrenching decisions about when to pull the plug on Aunt Sylvia or how to ration care in ways that most Americans would find unacceptable. The evidence from other countries is that, with U.S. health spending running at more than $2 trillion every year, we can buy all the health care we really need and still have some left over.

Steven Pearlstein can be reached at pearlsteins@washpost.com.

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