All this talk of late about evidence-based medicine has triggered a déjà vu overload. Reading about it, hearing the pros and cons, is like dialing the way-back machine to 1993, when Unforgiven won an Oscar, Dallas won the Super Bowl, Michael Jackson was still just weird, and President Bill Clinton's sweeping healthcare reforms were getting barbequed in Congress. The details are different, of course, and many of the players have changed, but the central question is essentially the same: What is the government's role in the nation's healthcare system?
Nestled in the historic $787 billion stimulus package that President Barack Obama signed into law last week is $1.1 billion for evidence-based medicine research. It seems innocuous enough when compared with the massive $87 billion in supplemental money to shore up Medicaid, the $21 billion to assist the newly unemployed with their COBRA coverage, or the $19 billion for electronic health records incentives. The relatively small change for EBM, (or comparative effectiveness research, as it's being called in Washington) however, has more potential for the biggest impact on the $2 trillion-plus U.S. healthcare system than any other item in the stimulus bill. It will also prove to be the most controversial item. Evidence-based medicine will prompt the fiercest and most vitriolic debate on the role of government in medicine since the plug was pulled on the Clinton plan 16 years ago. In fact the debate has already started.
We've heard the arguments from both sides; it's a variation on the old managed care riff. Advocates of EBM see it as the savior for the healthcare system; use the best data to find the best medicine and eliminate needless, dubious, and expensive medical procedures. Peter Orzsag, the newly appointed director of the White House Office of Management and Budget and a leading advocate for EBM, says that the nation's healthcare is expensive and inefficient because it isn't measured.
"We have a set of financial incentives that encourage more care rather than better care," Orzsag told a Robert Wood Johnson forum last year. "In order to change that we need to do a lot more testing of specifically head-to-head comparisons of what works and what doesn't and we need to pay for what works and not so much for what doesn't."
Opponents see evidence-based medicine as a blueprint for "cookbook medicine," where the course of treatment is taken away from physicians and dictated by the government, with cost as much of a determinant as efficacy. "Evidence-based medicine is just another fancied-up name for managed care. It is essentially moving towards universal one-size-fits-all medicine," says Twila Brase, president of the Citizens' Council on Healthcare, a St. Paul, MN-based privacy advocacy group. "We see the proponents of rationing healthcare using science to rationalize rationing."
Don't be surprised to hear a growing chorus of Republicans—desperate for wedge issues to launch against Obama and the Democrats—pick up on that theme. Talk radio leviathan Rush Limbaugh, inarguably the loudest voice in the GOP right now, has already weighed in, saying Obama's stimulus bill is the first step in the march toward socialized medicine. Limbaugh, of course, was a huge opponent of the Clinton health plan back in 1993, which apparently was also the first step in the march toward socialized medicine.
Former Republican Lt. Gov. of New York Betsy McCaughey, now a fellow at the conservative Hudson Institute, in a Feb. 9 column for Bloomberg, warned of a "new bureaucracy, the National Coordinator of Health Information Technology (that) will monitor treatments to make sure your doctor is doing what the federal government deems appropriate and cost effective. The goal is to reduce costs and ‘guide' your doctor's decisions." McCaughey was also a leading critic of Clinton's health plan.
With all these Clinton-era retreads popping up with the same arguments they had 16 years ago, we shouldn't be surprised if Harry & Louise stage a comeback too.
Interestingly enough, the health insurance industry—the fine folks who funded Harry & Louise and other ads designed to scare Middle America away from the Clinton plan—is now firmly in the EBM camp. "At a time when access to quality, affordable healthcare is a serious concern for many Americans, it is critical that our country make investments to create a sustainable healthcare system," says Karen Ignagni, president and CEO of America's Health Insurance Plans. "We must also ensure that patients and doctors have the information they need to evaluate the safety, effectiveness, and value of healthcare." Ignagni did not elaborate on the exact role that health insurance companies would play in determining appropriate—and cost-effective—care.
AARP CEO Bill Novelli, another EBM fan, told the association's 40 million members to be wary of the alarmist rhetoric. "They're at it again. Opponents of health reform are now using scare tactics in a misguided attempt to stop progress in its tracks, blocking attempts to fix the broken healthcare system that is hurting American families and our economy."
Novelli says the static is coming from "opponents—like some drug companies and medical device makers—that don't want this research. They fear it will cut the profits they make on ineffective drugs and equipment."
These are just the opening salvos!
Here's how I see things playing out at a date in the not-too-distant future. The largest, wealthiest, best-organized, most influential industries and public interest groups, and the Obama administration are forming ranks to fight it out over a program that could fundamentally reshape healthcare, and redefine the government's role in determining how care is delivered.
Potentially, trillions of dollars are at stake. In Congress, this fight will almost assuredly break upon already entrenched partisan lines. Everything else does. The rancorous debate will come in the middle of the worst recession since the Great Depression, with millions of Americans out of work, or gravely anxious about their prospects, angry, politically aware, and in no mood for partisan grandstanding.
To borrow another term from the early 1990s, attributed to the late but not lamented Saddam Hussein, this will be the mother of all battles.