A Vision for Health Care: Put the States in Charge

In an ideal world, all our doctors would have the wisdom of Marcus Welby, and all our nurses the compassion of Florence Nightingale. This medical world would be populated with doctors who all graduated No. 1 in their classes, who perform only necessary surgery — and without complications. These doctors would always wash their hands between patients to minimize the spread of infection. All medical research would be funded by nonprofit foundations to preclude bias. And, of course, all doctors would be salaried to avoid perverse incentives to do too much to too many.

Recently, the United States Preventive Services Task Force recommended against prostate-cancer screening, saying it doesn’t save lives overall and often leads to additional tests or treatments that do harm. Two years ago, the same task force, which is made up of nonfederal experts in primary care, recommended against screening mammography for women in their 40s.

What would Dr. Welby and Nurse Nightingale have said about the task force recommendations? I believe they would have endorsed them, because they are carefully researched and objective.

Yet both recommendations have been met with widespread protest. The task force has been accused of rationing — the dirtiest word in American medicine.

Why? Because a chasm separates the idealized world of American medical practice and our current reality.

The excesses and errors of American medical practice have created a system that is often hazardous and always costly. The oft-repeated refrain “we have the best medical care in the world” is not just off the mark but wildly wrong. According to the World Health Organization, we rank 22nd compared with the other 23 developed countries.

The costs of our current system are too high and will soar as the baby boomers retire. The Medicare Trustees have estimated that the nation faces $89 trillion of unfunded Medicare liabilities for current and future retirees.

Yet despite the glaring shortcomings of American medical care, reform is impeded by public misconceptions. We conceive of medical treatment as positive, by definition, despite mountains of evidence to the contrary. It’s essential that we reduce Medicare costs, but we can do this only by reimagining health care.

We must escape from dreamland and see health care for what it is.

Few people realize that having health insurance in the United States confers no mortality benefit. People with health insurance do not live any longer than those without health insurance. That is what Dr. Richard Kronick uncovered in his seminal article published in Heath Services Research in 2009.

In 1999, the Institute of Medicine published its epic study “To Err is Human; Building a Safer Health System.” It revealed that medical errors caused as many as 98,000 deaths and more than a million injuries each year in the United States.

According to an article published in the New England Journal of Medicine in November 2010, things have not improved in the last 10 years. Though safety efforts have been many, they have done little to reduce deaths and injuries caused by medical treatment.

Studies published by the Office of the Inspector General of the U.S. Department of Health and Human Services in November 2010 and by the journal Health Affairs in April 2011 corroborate this dismal condition. They revealed that between 27 percent and 33 percent of hospitalized patients are harmed by medical treatment.

Add to this the 2011 study published in the American Journal of Epidemiology by American and Dutch researchers. It demonstrated that despite double the per capita spending on health care, Americans have inferior health to the English. That includes all age groups studied — from childhood to age 80.

All of these excessive costs, medical interventions and harms done by medical treatment support a rather astounding conclusion in another body of medical evidence.

Published studies from 2004 and 2007 in the Journal of Pain and Symptom Management demonstrate that patients hospitalized with exacerbations of serious chronic illness (e.g., heart failure, emphysema, cancer) on average live longer if they choose hospice care.

That’s right, patients who declined aggressive medical treatment in favor of care that focuses on comfort and quality of life actually lived longer. As an added bonus, patients in hospice live better until they die and experience more comfortable deaths. Their surviving family members are healthier. And they cost the health care system a lot less.

So what should our country do? We have spent ourselves into an enormous debt. The debt will explode as baby boomers retire unless we control medical costs. Incentives in the current system foster more spending. Pervasive conflicts of interest lead doctors, hospitals, drug and medical-device companies to promise much while delivering much less.

Will President Obama’s Affordable Care Act legislation substantially alter the current dysfunction? Doubtful.

Will the plan by Republican U.S. Rep. Paul Ryan to privatize Medicare help? Even more doubtful.

The default assumption has always been that more health care is better than less, and that newer treatment is better than older. This is a very expensive assumption — and all too often erroneous.

We must reimagine health care. If we do, we can separate the wheat of beneficial health care from the chaff of health care that is of dubious value or no value, or even does harm.

There is a way to solve this problem, and to place Medicare on a path of fiscal solvency. A system can be created — cut from old cloth — that could powerfully reconfigure the incentives of the Medicare program. The old cloth is the current Medicaid system.

In Medicaid, there is dual funding — federal and state. States have considerable flexibility to design their own eligibility rules and benefits for their individual programs.

Medicare could be set up similarly. Allow each state to define its Medicare benefits. States would use nonbiased medical research sources such as the Cochrane Collaboration (www.cochrane.org) and the Preventive Services Task Force. The key to the success of this program is shared savings.

Most of the states, as well as the federal government, are in terrible financial condition. Redesigning Medicare, allowing states to assemble benefit plans based on — of all things! — medical benefit and to recoup a share of the savings would lead to huge efficiencies. The incentives of the system would change. Reimbursement for medical treatment would be based on actual medical benefit.

Critics will scream that such a system would be tantamount to rationing. However, curtailing access to unnecessary, unproven or even harmful medical treatment is anything but rationing. We would be allowing the wisdom of unbiased medical research to drive decisions.

The state and federal governments, Medicare — and its recipients — would all be healthier.

Victor M. Sandler is an internist, geriatrician and hospice and palliative medicine specialist. This post first appeared in the Star Tribune.

7 replies »

  1. I hate to advocate the Canadian system (and I don’t) but this is how the Canadian system runs. Provincial governments run the single-payer plans and the federal government gives (what we’d call in the US) block grants. And the federal share is only about 30%! In the US, Medicare is 100% federal funded and Medicaid over half. In Canada, the federal government doesn’t fix doctors’ fees or regulate hospitals. This is something both left-wingers and right-wingers should agree on: Give health care (back) to the states.

  2. It’s too bad that such a thoughtful and informed analysis of the problem is followed by far too sweeping a solution.

    Turning Medicare and Medicaid over to states could lead to better systems — in some cases — or to disasters — in others. It’s easy to imagine that the State of Oregon, for example, would do a better job than Washington DC of health care resource management if it had full control over current federal programs (and Governor KItzhaber is an articulate and knowledgeable proponent of the potential advantages). On the other hand, it’s just as easy (at least for me, having worked with Medicaid programs in twenty states) to imagine the mess that would ensue in other cases.

    So here’s a suggestion, already supported by several US senators: move the date for ACA state waivers up to 2014, allowing states that can persuade HHS of their competence and ability to meet the standards of the law to do so without imposing two separate transitions on their populations.

  3. “According to the World Health Organization, we rank 22nd compared with the other 23 developed countries.”

    Since when so we care about losing high school popularity polls? WHO rankings are junk science and mean nothing, its just propoganda fodder.

    What stats that make up their ranking have any meaning?

  4. “Allow each state to define its Medicare benefits”

    And how could they afford it? Look at the very restrictive qualification rules for Medicaid, yet states still can’t pay for it. Do you want those same (or worse) rules for Medicare – if so then how loud will people scream “RATIONING!” or “DEATH PANELS!” then?

    The states should be allowed to administer the federal program with federal funding assistance for standard federal system benefits and rules. That would mean no race to the bottom as states compete to lower taxes and would help workers be able to migrate to jobs with no loss of healthcare or benefits.

  5. “Allow each state to define its Medicare benefits. ”

    Right. I’ll just hold my breath ’til the votes in Congress materialize to change that aspect of the Act.

    Are you SERIOUS? That is simply a non-starter. Notwithstanding the truth of the many treatment and clinical outcomes problems you cite.

    Providers my my state (NV) get roughly half the Medicare rate for seeing Medicaid patients (and, our state toyed with the idea of getting out of Medicaid entirely).

    I would invite everyone to review this:


    In the black big-time off Medicare patients.