Saturday, May 22, 2010

The Conservative Healthcare Conundrum

Cross-posted from The Agenda on National Review Online.

While I am an admirer of Massachusetts psychiatrist Alexander Vuckovic for his role in electing Scott Brown, his most recent missive to The Weekly Standard contains a contradiction that dogs many Obamacare critics: if we are opposed to Sarah Palin’s death panels, are we simultaneously for unlimited government health spending?

Many more Republicans have criticized the former than have proposed solutions to the latter. And unsurprisingly so, since none of the solutions to runaway spending are politically riskless.

Case in point: On May 7, Mark Thornton, a veteran of both the FDA and the biotechnology industry, wrote an op-ed for the Wall Street Journal. In it, he blasted the FDA for delaying for three years the approval of Provenge, an innovative new treatment for prostate cancer. “In the three years that it took to duplicate what was already known,” wrote Thornton, “upwards of 80,000 men lost their lives to prostate cancer. This is equal to the number of men killed in combat in the Korean, Vietnam and Iraq wars combined. Those FDA staffers who had a role in preventing the approval of Provenge in 2007 will have to live with this sin of omission.”

In response, a physician named James Smith, of Macon, Ga., wrote a letter to the Journal, pointing out that Provenge is not cheap:
Provenge will cost about $90,000 to $100,000 per treatment and will add about four months of life, on the average, to the population of patients who receive it. It is considered a palliative medicine, not a cure.

Therefore, in that three-year period Dr. Thornton cites, the 80,000 patients would still have died, only four months later at a cost to society of $8 billion.

I do not know if Dr. Thornton will lose much sleep over this issue, though he should if he is concerned about how the money could have been better spent...Progress in our war on cancer comes in small, incremental steps. Small advances at tremendous cost, claimed as major victories, may exhaust the warriors before true victory can be achieved.
Which brings us back to Dr. Vuckovic, who was outraged by Smith’s skepticism:

[Smith] notes—triumphantly!—that the drug sells for $90,000 to $100,000 per patient and will only extend life an average of four months at a “cost to society” of $8 billion for the theoretical (not actual—they’re dead, you see) treatment of 80,000 patients who died during the extended drug approval period. To put it in perspective, that’s 26,000 patient years of life which would have been apportioned to men who would have had a chance to see sons graduating, daughters married, grandchildren born, perhaps wonder one last time at the pyramids of Egypt or the Grand Canyon. And remember—an average of four months translates to anywhere from zero to a year or more of life in that population, as well as including a few actual cures. To Dr. Smith, however, those cancer patients had a duty to die sooner so as to relieve us of the burden of the cost of their care. That a physician can make such an argument and at the same time act morally superior to the rest of us is an indelible bloody stain on my profession. President Obama’s most recent health-czar designate is an unabashed admirer of the British National Health Service, where the Dr. Smiths of the world make the life-and-death decisions. This is the future of American medicine unless we rise up and repeal the Obamacare monstrosity which will soon be gently reminding us all of the duty to die cheaply.
While I am no fan of the FDA’s bureaucratic tendencies, nor of Britain's NHS, Smith’s concerns are actually quite reasonable. Indeed, it is Vuckovic who overstates his case. After all, as Smith notes, Provenge is not a cure for prostate cancer—but merely a treatment that will extend life by an average of four months. (Vuckovic gets his facts wrong here: Provenge does not result in any actual cures of hormone-refractory prostate cancer; HRPC remains an incurable disease.)

Clearly, in a perfect world, it would be better if we could give Provenge to everyone, just as it would be better if we could give free health care to everyone. Vuckovic, by asserting that no one should be denied Provenge, is unwittingly making the argument for the very kind of socialized medicine he thinks he despises. Given that 65% of prostate cancers are diagnosed in men over 65—i.e., men on Medicare—this is not a theoretical question.

Here is the basic problem. If the state pays for our health care, then the state has a responsibility to ensure that it is paying for cost-effective treatments; otherwise taxpayer dollars are wasted. It is precisely because politicians are afraid to say no to seniors that companies can overcharge Medicare. Spiraling health-care inflation, in turn, leads the government to strike back with unelected bureaucrats who can relieve politicians of that responsibility.

In other words, death panels are the necessary corollary of government-funded health care: once government is paying for health care, government must decide how much it is willing to pay to keep someone alive. The British, unlike many of Obamacare’s advocates, are intellectually honest enough to admit this, and explicitly put a price on the value of a year of a Briton’s life.

On the other hand, the logic of opposing death panels leads necessarily to restructuring the government’s role in funding health care. Precious few Republicans—Paul Ryan excepted—have proposed a way to do this.

The more that individuals are responsible for their own health spending, the more freedom they will gain to seek expensive or inexpensive treatments, based on their own priorities and needs. If Americans want others to pay for their care, they will need to accept that others will decide how they will be treated. I hope we choose the former route.


  1. The cost of Provenge is well known. It is quoted often by physicians and others against the vaccine. Why is there never a quote on the price of chemotherapy over the same time period. Ans while you are quoting chemo, please add the cost of lessening the side effects. Provenge was priced to be COMPETITIVE with chemotherapy. Secondly, the cop-out of saying it only adding 4 months is a poor comparision. If you are counting quality time from the start of treatment, add the months that chemo allows you to do nothing but lay around and feel deathly ill from any side effect not resolved. Where would medicine be if we only allowed advances that cured us of an ill?

  2. Hi Anonymous,

    Provenge does not replace chemotherapy -- it will be used after, before, or simultaneously with chemo. Though Provenge has benefits, I'm not sure that avoidance of chemotherapy is going to be one of them.

    But my concern isn't so much about Provenge specifically -- but about a system that encourages us to demand extremely expensive therapies without encouraging us to think of their cost. Liberals say, "we can give you free healthcare by letting other people pay for it." Conservatives say "government shouldn't restrict your healthcare choices, even if government is picking up the tab." Neither approach is sustainable.

  3. Thank you for tackling an unsavory topic.

    It is slightly OT to your discussion, but some of the expensive treatments now paid for by Medicaid/Medicare don't always improve quality of life.

    My grandmother was given bypass surgery ten years before she died. It may have extended her life but the effect of the extended anesthesia on her mental facilities meant she came out of the operation not knowing who her children were or where she lived. She went from being self sufficient to utterly dependent.

    She and her children were never warned of this side effect, but a gerontologist told us after wards that at her age and with her symptoms of mental decline (that had until that time been manageable) it was a near certainty.

    Never mind that it destroyed her mind though! It prolonged her life! And society paid for us. Hooray for us.

    Don't even get me started on chemo -- for many cancers it really isn't effective. And relative vs. absolute risk.

  4. Hi CG,

    Thanks for your comment -- you make a lot of important points. You hint at an important ethical issue that politics is not well-suited to addressing: what is the balance between seeking to extend life and focusing on quality-of-life?

    My view is that these choices are deeply personal, and are rightly the province of individuals and their loved ones. No bureaucrat or politician should force a uniform view on such matters upon a large slice of the population.

    Single-payer systems like Medicare encourage just this sort of political thinking, however, by incentivizing overutilization of health care without understanding why that overutilization is happening. It happens because the only people in a health care system that are truly equipped to judge the balance of cost and benefit are individual patients, their families, and their doctors.

  5. To clarify that last sentence: the current Medicare system, by heavily subsidizing healthcare consumption, gets an unnaturally high amount of it (surprise!). Policymakers see the overconsumption, and then devise bureaucratic strategies to micromanage medical practice.

    A better solution would be to use cost-sharing mechanisms to make more patients aware of the costs of choices they make, and to incentivize them to make the choices that truly balance value and price.