Sunday, September 1, 2013

Rand Paul on health policy: small brain and no heart

While politicians are rarely elected to office because of their profession (I seem to remember that when in elementary school we learned that the second most common profession in the NY state legislature, after attorneys, was undertakers!), the fact is that often fellow legislators often turn to their colleagues with expertise in a certain area to understand bills with technical implications. Legislators who are physicians, nurses and pharmacists, for example, may have influence on bills related to health care. (This is provided, of course, that they don’t involve touchstone ideological issues like abortion where facts are routinely ignored and new ones, such as “abortion causes breast cancer”, are invented.) Thus, physicians like former US Senate Majority Leader Bill Frist, a cardiac surgeon (and member of the family that founded and controlled HCA, the nation’s largest for-profit hospital chain) had great influence on medical matters.

So it is relevant to look at statements by Sen. Rand Paul (R, KY) about healthcare. Primarily known as a prominent libertarian conservative and Tea Party favorite, as well as a probable Republican presidential contender, Paul is an ophthalmologist, an eye surgeon, and thus probably is presumed to have credibility on healthcare issues. This does not seem to be diminished by the fact that he has not been Board-Certified by the mainstream American Board of Ophthalmology since 2005, being rather certified by the National Board of Ophthalmology, which, coincidentally, he founded and is president of (the Louisville Courier-Journal link is no longer live, but it is referenced in TPM). Perhaps this appeals to his libertarian base; perhaps it even is honorable if it is truly based (as he states) on “…a principled stand in response to the ABO’s ‘decision to grandfather in the older ophthalmologists and not require them to recertify….I thought this was hypocritical and unjust for the older ophthalmologists to exempt themselves from the recertification exam.’

So what does Sen. Paul have to say about important health policy issues? Unsurprisingly he is a strong opponent of “Obamacare” and, for that matter, any universal healthcare system. He apparently has a fair amount to say about this it in his book, “Government Bullies”, which I have not read. I did, however, hear him discuss it at some length with John Oliver on a “Daily Show” appearance on August 12, 2013. His main point is that, unlike “most legislators” who have “dinosaur syndrome -- small brains and big hearts” (news to me about politicians, at least the “big heart” part. And, by the way, where does he get the idea that dinosaurs had big "hearts" other than in the physical sense?), he can help solve problems because he is not in that mold (I think he was referring to the “small brain” part, but I’m not sure!). He called upon his experience as an eye surgeon to demonstrate how the “market” controls costs by referring to how it led to big price drops for two major procedures in his specialty, Lasik® surgery and contact lenses. With regard to the former, he notes that competition among ophthalmologists has led to dramatic decreases in charges (and costs) from over $2000 an eye to less than $500. The competition for contact lenses was with large retailers like Wal-Mart, which forced him to drop his charges in order to compete. Neither was covered by insurance, so he uses them as examples of how this could work for all the other things that are covered by insurance and to which people are price-insensitive.

All but the last of these assertions are true as far as they go. The cost of both Lasik® and contact lenses have indeed dropped. So, will this work for all health costs? No, absolutely not. There is a reason that these two procedures are not covered by insurance; they are both elective procedures and thus (like cosmetic surgery and many consumer items) can be reasonably subject to market forces. One has a much cheaper and effective option that works for the medical problem: wear glasses. If you are considering Lasik or contact lenses, you can choose to not buy them now and wait until prices come down. However, most of healthcare is not elective (thus more like food and housing). Emergencies are emergencies and need to be addressed now, by the most available provider (see The high cost of US health care: it's not the colonoscopies, it's the profit, July 28, 2013, for a discussion about how hospitals like Bayonne Medical Center have turned this into a profit-making strategy).

Mark Ebell, MD, a family physician and expert in evidence-based medicine, notes a more apt comparison: “If you have a stick in your eye, I doubt that you are price shopping or waiting for ads on the radio to advertise a special for removal of sticks in the eye.” No doubt; and while not all necessary healthcare is about emergencies, most of it is not about elective procedures. Chronic diseases like hypertension and diabetes need to be treated in order to prevent their progression to serious outcomes. Preventive care like screening for cancer and immunizations are only of value if they happen before the onset of disease. Neither Lasik nor contact lenses prevent either disease or its progression. 

Dr. Ebell is unhappy that Mr. Oliver, usually quite clever, completely missed this point, and it is an extremely important one. While I do not know if Sen. Paul is aware of this and is dissembling in using this inappropriate and simplistic example as a justification for his anti-government ideology, or is he actually believes it, the fact is that it is not at all a valid argument for a market-based health system. The empiric evidence is there, both in comparisons to other developed countries and in internal comparisons between state and local experimental government and insurance programs in the US: providing comprehensive health care at costs that do not discourage or make it impossible for people to access it improves health status. Conversely, there is excellent evidence that obstacles to healthcare access do discourage people from seeking it and do result in worse health outcomes, for individuals, populations and nations.

The danger in an argument such as Sen. Paul’s is two-fold. One is that, coming from the Republicans’ most prominent physician, it will reinforce the beliefs of those who already think that the market will solve the healthcare crisis. The other is that people who are not such ideologues but whose exposure to the health system, because of a fortunate combination of relative youth, good health, and economic security, is largely for such elective, minor or episodic care, may say “yeah, that seems right”. But it isn’t; it’s wrong. A recent NPR “Marketplace” show focused on the ACA’s requirements for individual health insurance policies that preclude many low-coverage, high-deductible options currently available.[1] It featured a self-employed Californian who noted that he was having to pay much more for insurance now, even though he was never sick and, in the last 14 years, had visited a doctor only a few times. It didn’t give his age, but whatever it was he will, in the future, be older; this is a certainty. And, as we get older the probability of needing health care increases. The old maxim about the stock market – that past performance is not a guarantee of future performance – is even more true for one’s health. It is at best risky and at worst foolhardy; the more apt comparison may be to the person who falls off a 20-story building and is heard by people as he passes each floor saying “so far, so good”. Making public policy on such a basis is nonsensical.

Dr. Ebell  says, regarding Sen. Paul’s analysis, “it makes me crazy. Big brain and no heart is a bad combination.” He is right about that, but more important is that there is no evidence that Sen. Paul’s analysis indicates big brain at all.

[1] For a good discussion of the insurance exchanges, see Harvey Matoren’s blog The Patient’s Advocate” for August 21, 2013, and for a state-by-state portrayal of federal/state involvement in the exchanges, the Commonwealth Fund website,

No comments:

Total Pageviews