The White House prefers to emphasize the positive, but of course Robert Pear is right to point out that achieving the kind of cost controls envisioned at yesterday’s kumbaya session is easier said than done. This is much more reasonable than paranoid arguments about comparative effectiveness research leading to large-scale denials of care. There’s a substantial risk that even if we identify wasteful practices, they won’t actually be curbed because one man’s waste is another man’s profits and that second man has a lot of lobbyists and PR people working for him.
For example, in most jurisdictions teachers automatically get higher salaries if they acquire certain advanced degrees. The thinking behind that is presumably that acquiring such degrees makes the teachers more effective, so it makes sense to provide them incentives to get the degrees. The evidence, however, is quite clear that obtaining the degrees doesn’t make the teachers more effective. But the mere fact that we know the current system is wasteful doesn’t compel change in part because some people benefit from the waste and in part because opinions and interests differ as to where the currently wasted resources ought to go.
That said, while people shouldn’t have illusions about the idea that it will be simple to wring efficiencies out of the health care system, it’s clearly the case that systematic reform is the best hope for doing so. Precisely because it’s hard to cut waste, the dynamics of the current system encourages everyone to focus their energy on shifting the around since that’s easier than actually eliminating them. The more comprehensive you make the system, however, the more explicit the tradeoffs become between providing services and paying for services. That at least creates a framework in which it’s possible to think coherently about where efficiencies could be found.