Leonhard on Prostate Cancer

David Leonhardt has a brilliant article on prostate cancer treatment. But of course it’s not really an article about cancer treatment at all, rather it’s an article about the need for payment reform in the health care system. To make a long story short, if early-stage prostate cancer is discovered there are a variety of possible treatment modalities and they cost different amounts. In principle, there could be a tough choice between a cheap and somewhat effective treatment and an alternative treatment that’s much more expensive and only a bit more effective. But in practice, we don’t even face that choice. It’s not actually clear how effective the different options are. And nobody’s really researching the issue. And even if they did, health care providers just get paid for delivering health care services not for delivering effective treatment.

So the incentive at the moment is for the whole system to push everyone with good insurance toward the highest-cost option and everyone without it to the lowest-cost option, all flying totally blind as to what works and for whom and why. It’s a great piece. I disagree a bit, however, with the tenor of Leonhardt’s conclusion. After quoting Senator Ron Wyden (D-OR) to the effect that the current legislation doesn’t go as far as one would like in changing this dynamic, Leonhardt concludes:

The current health care system is hard-wired to be bloated and inefficient. Doesn’t that seem like a problem that a once-in-a-generation effort to reform health care should address?

For one thing, it’s just wrong to imply that the bills currently in congress don’t address this issue. Leonhardt says as much earlier. They just don’t address it as fully or as robustly as one would do in an ideal world. But forward progress is forward progress. More important, I don’t think we should see this as a “once-in-a-generation effort.” The idea that there need to be big gaps between health reform pushes comes from the history of failed reform pushes. The 1994 health care blowup made politicians afraid of dealing with the issue. A successful bill would have the reverse effect. And even in the case of failure, the 15 year gap between 1994 and 2009 isn’t exactly a generation. And it’s worth noting that we had a major Medicare bill as recently as 2003. And of course there’s the long-run budget outlook:

That’s not sustainable, so whether or not politicians want to they’re going to need to keep addressing issues related to systemic health care cost growth.

Additionally it’s worth noting that part of the issue here is that without a track record of legislative initiatives in this area, it’s difficult for members of congress to write legislation that results in budget savings that the CBO will score. And hard as it is to take a tough vote to save money, it’s really hard to take a tough vote to save money that you don’t even get credit for. The only way around this is to start taking some modest steps and hope that modest steps produce modest gains that establish a track record and lay the basis for further efforts.