by Maggie Mahar
Dick Morris, the former political adviser to President Clinton who is now a ubiquitous gadfly commentator, denounced the White House for not being truthful about what health care reform will mean in a recent column posted on The Hill. Morris’ piece, titled “The Death of American Healthcare” seems worthy of analysis because he does such an able job of packing so much misinformation into a relatively small space:
Falsehood #1: We’ll Lose Our Doctors!! Morris begins by charging that “when America’s top health insurers and providers met at the White House and pledged to save $2 trillion over the next decade in health care costs, they were in fact pledging to sabotage our medical care. The blunt truth, which everybody agreed to keep quiet, is that the only way to reduce these costs is to ration healthcare, thereby destroying our system.”
He goes on to “explain” how reformers will destroy American health care: by slashing doctors fees. Morris writes: “Congress is trying to cut Medicare fees by 21 percent.”
The Facts: Everyone in Washington knows that Congress is not going to slash Medicare fees to doctors by 21 percent. The budget President Obama submitted to Congress didn’t even pretend this might happen. The president assumes that Congress will halt the scheduled cut in payments from Medicare to physicians, just as it has in the past — including last summer when the Senate voted 69 to 30 against across-the-board cuts.
It would have been easier for Obama to pretend that draconian cuts would go through (as President Bush always did). That would have made President Obama’s budget look better. But instead, Obama’s budget proposed setting aside $11.7 billion to maintain doctors’ fees at their current level in fiscal 2010.
Nevertheless Morris insists that doctors’ incomes will plummet and that this will “just discourage people from entering the profession and those already in it from practicing. The limited number of doctors and nurses in the United States is the key constraint on the availability of health care. Our national inventory of 800,000 doctors is growing at only about 1 percent a year (18,000 med school graduates annually minus retirements), while the nurse population is stagnant at 1.4 million. To stretch these limited resources so that they can treat 50 million more people is possible only through the most severe kind of rationing.”
But although we are experiencing a shortage of primary care physicians throughout the U.S., we have more specialists than we need in much of the country. One might think that a town can’t have too many doctors. But in truth, excess capacity leads to over-treatment, and poorer outcomes.
As researchers point on in a 2006 study published in Health Affairs, “regions and states with more medical specialists and general internists appear to have lower quality of care as measured by mortality and common performance measures endorsed by the National Committee for Quality Assurance (NCQA).”
Patients in regions with more doctors are twice as likely to be seeing ten or more physicians during the final two years of life, and end-of-life care is usually much more aggressive. Yet outcomes are no better, and often they are worse. A 2009 study published in Health Affairs reveals that patient satisfaction is significantly lower when patients are seen by more physicians — and the technical quality of care also is lower. Researchers suggests that having too many physicians [may] lead to “disorganized care and duplication of services” and that this many explain “not only for the poorer performance on technical quality measures … but negative hospital ratings” by patients.
The problem is that more doctors mean that “more happens to the patient,” but it doesn’t mean that the patient receives the coordinated, compassionate care that he needs. Too often, ten specialists see the patient as ten different body parts: a heart, kidneys, lungs, a breast — all in need of different treatments. A patient may be dying of congestive heart failure, and yet is subjected to a mastectomy (because a test discovered cancer), or hooked up to a dialysis machine. It is not that most doctors are intentionally over-treating, but that they have been trained to do “everything possible” to treat a particular organ. Patients get lost in the crowd.
Meanwhile, the authors of the 2009 study point out that when too many doctors are involved in a case, physicians themselves are frustrated: “A survey of physicians found that … in regions with more physicians, where patients saw more specialists, doctors also reported ‘that both the continuity of care with their patients and the quality of communication among physicians were inadequate to support high-quality care.’”
Some assume that, as boomers age, we will need more doctors. But as I have explained, boomers will age as they were born — over a period of decades. We are not going to be hit by a tsunami of wizened hippies. Over those decades, we will adjust to changing needs; very likely, we will be making greater and better use of nurse practitioners.
It is true that, today, we are experiencing a shortage of nurses. But this is not because of a shortage of applicants to nursing school. The problem is that we don’t have enough nursing school professors to teach them. This is a problem that can be remedied quite simply by raising pay for underpaid nursing school teachers. As the supply of nurses rises, working conditions will improve; today, too many nurses are working in understaffed hospitals. We also need to hike pay for many nurses — but this will be much less expensive than training and paying for more specialists than we need.
Falsehood #2: We’ll Die of Cancer — Just Like the Canadians!
Morris goes on to suggest that under health care reform, we’ll be deprived of needed treatments: “As in Canada, the best way to cut medical costs is to refrain from using the best drugs to treat cancer and other illnesses, thereby economizing at the expense of patients’ lives … death rates from cancer are 16 percent higher in Canada than in the United States. We will pay for the attempt to save $2 trillion with our lives.”
Facts: Let’s start with the assertion that death rates from cancer are “16 percent” higher in Canada. What does that mean? To understand, one needs to look at specific diseases. For example , consider breast cancer. Public health data shows that while only 20.7 Americans die of breast cancer, 22.4 Canadians succumb to this disease.
But this raises an obvious question: 22.4 out of how many? The answer: 22.4 Canadians out of 100,000 succumb to breast cancer. So while 22.4 represents an 8 percent jump from 20.7, if you step back and think about it, the risk in Canada is just a hair higher. In truth, the odds that the disease will kill you are very, very low in both countries.
Looking at “percentage differences” when comparing the small number of people who die from a disease is a common trick that many conservatives use when trying to prove that the U.S. has “the best healthcare in the world.”
Of course, they leave out the numbers that don’t serve their case. For instance, while 47 out of 100,000 Americans die of lung cancer, only 46.2 Canadians are felled by this disease. The number of deaths from colorectal cancer is somewhat higher in Canada (18 out of 100,000 vs. 14.4 out of 100,000 in the U.S.) But again, the fact is that the chances that you will die of colorectal cancer are very, very slim in both countries.
Conservatives like Morris don’t want you to know that. They want to play on your fears of a dreaded disease, and suggest that if the U.S. goes so far as to extend healthcare to all Americans, you will be in danger. So Morris writes: “In Canada, colonoscopies are so rationed that the colon cancer rate is 25 percent higher than in the U.S. (even though Canada has a much smaller proportion of poor people, whose frequently bad diets make them more prone to the disease).” Keep in mind, he is talking about the extra 3.6 people out of 100,000 who die of colon cancer in Canada.
Maybe Canadians should be undergoing more colonoscopies. But a study funded by the National Cancer Institute and published in the Annals of Internal Medicine reported that American physicians are doing too many of these very lucrative procedures. “Researchers found that 24 percent of gastroenterologists and 54 percent of general surgeons recommend surveillance colonoscopy for small, hyperplastic polyps. For patients with single small, low-risk adenomas, many of the physicians recommend surveillance every three years, or even more often.”
“Evidence-based guidelines, in contrast, call for no extra surveillance after removal of a hyperplastic polyp, a benign growth not believed to become cancerous. And while the guidelines do recommend surveillance colonoscopy following removal of adenomas, which can develop into cancer, at most the exams are recommended only every three to five years.”
“We believe colonoscopy can be a life-saving procedure, but it shouldn’t be done more often than necessary,” Dr. Pauline Mysliwiec the study’s lead researcher explained. “When it’s used inappropriately, it puts patients at unnecessary risk.” Risks include a punctured colon.
Responding to the rising number of unnecessary colonoscopies, the U.S. Multi-Society Task Force on Colorectal Cancer and the American Cancer Society jointly issued new guidelines in 2008, recommending that low-risk patients undergo the procedure only every 10 years.
Falsehood #3: We’ll Lose Our Drugs! Morris claims that more Canadians die of cancer because they don’t have enough cancer drugs.
Facts: First of all, the statistics show only a tiny difference in the number of Canadians who die of cancer. So lack of drugs cannot be a big problem. Secondly, in the U.S. some oncologists complain that there are too many cancer drugs are on the market, and that the vast majority just aren’t very effective. Too many set the patient up for false hopes — and subject him or her to additional side effects — while prolonging the process of dying.
“The truth is that there is no clearly effective chemotherapy for a distressing number of malignances,” says Dr. Peter Eisenberg, an oncologist in Northern California who has served on served on the board of the American Society of Clinical Oncology and the Association of Northern California Oncologists.
In the late 70s and 80s, Eisenberg says oncologists were more enthusiastic about cancer drugs. “If a patient had cancer, and we knew that tumors responded to a certain chemotherapy regimen by shrinking, physicians assumed that the patient should have it. It was not until much more recently that the notion of quality of life, and the fact that just because we shrunk a tumor doesn’t mean that people will actually live longer, was clear to us,” Eisenberg observes.
While it is true that Canada is slower to approve some of these drugs than the U.S., this does not mean the difference between dying of cancer and being cured. Consider Avastin, a drug that Canada approved to treat colon cancer in 2005-18 months after it had been approved in the U.S. Avastin costs the average U.S. patient $53,000 for a year’s supply. Meanwhile, clinical trials show that patients who receive a combination of chemo and Avastin live just 5 months longer. During those 5 months, patients are likely to experience common side effects of the drug including diarrhea, mouth sores, tiredness and weakness, headache and loss of appetite. Rare, more serious side effects can include “holes in the colon requiring surgery to repair; bleeding leading to disability (stroke); and kidney damage.” In other words, quality of life during those extra months is not likely to be very high.
Do you wonder why Morris doesn’t cite any sources for his numbers? Because the numbers just aren’t true.
Falsehood #4: We’ll Lose the Best Health Care in the World! Dick Morris concludes his rant with a flourish: “once the healthcare system is extended to cover everyone, with no commensurate increase in the resources available, the change will be forever. The vicious cycle of cuts in medical resources and in the number of doctors and nurses will doom healthcare in this country. This wanton destruction will not be reversible by any bill or program. A crucial part of our quality of life — the best healthcare in the world — will be gone forever.”
“Politically, voters will feel the impact of these ‘reforms’ very quickly,” Morris adds. “When they face rejection or limitation at the hands of the bureaucrats, they will quickly understand that the their options have become limited. Just as in the 1990s, when HMOs first became universal, the patient outrage will create a political force all its own and those who foisted this brave new world on the American people will be in their crosshairs.”
Fact: Virtually no one, except perhaps George W. Bush, still tries to make the claim that the U.S. has “the best health care in the world.” In the film of Money-Driven Medicine, Dr. Donald Berwick, founder of the Institute for Healthcare Improvement, makes it clear that we don’t have the most effective care — “we just have more care.” We do have some very hi-tech care that can “rescue” certain patients, but here were are talking about a tiny percentage of health care — probably less than 1 percent. When it comes to treating and controlling chronic diseases, we don’t have the best health care in the world.
In just seven sentences, Morris manages to claim that reform will mean the death of American health care. “A crucial part of our quality of life … will be gone forever” and that “patient outrage” will overturn “this brave new world.” To say that our current system will be forever gone — and to say that health care reform will be overturned might seem like a contradiction. But propagandists like Morris don’t worry about logical flaws in the content of what they are saying. There is no content. The rhetoric is all about style. When you’re spinning, it’s just a matter of hitting the right high notes, buzzwords like “our quality of life” … “brave new world” … “in their crosshairs.”
A false appeal to patriotism, an appeal to the fear of change that we all share — and a plug for rifles — a perfect coda.
