An Empty Hand

President Obama's odds of enacting major health care reform this year are worse than winning at blackjack, despite the fact that it's his game, at his table, and with his dealer.

Democrats are going to stumble under the weight of their own unwillingness to compromise on some key policy prescriptions: ideas that make their plan unnecessarily costly and politically vulnerable. This starts with an insistence on erecting a public insurance option, modeled off Medicare, to compete with private health plans--a proposal that at once is both a budget buster and a killjoy to bipartisan compromise.

Then there are the plans for a "federal health board" and a new agency devoted to "patient centered health care research" (gone is the phrase"comparative effectiveness research"--apparently the White House found it didn't poll well). These latter two proposals invoke images of Canadian style cost controls, wait times for new knees, and faceless bureaucrats adjudicating who gets access to medical treatments according to Congressional rather than clinical prerogatives.

The Congressional Budget Office will soon speak. The costs will be astronomical.

Now it's true that, so far, no policy arguments are even bumps in the road to the Democratic plans. But the over-reach of Washington control of individual medical decisions by scary sounding new agencies (it took real genius to name it the "health board") is eventually going to resonate badly with regular voters.

In the end, the real flaw in Obamacare is the underlying premise that to trim costs we need to expand government control over health care. Our problems exist not in spite of government intervention but precisely because of it. As the biggest purchaser of health care, Medicare overpays for commodity products (wheelchairs) and underpays for essential services (disease management). A remote and largely clinically deficient entity, Medicare has no ability to match spending to incentives that actually improve care delivery--creating misalignments that permeate through our entire system.

The Congressional Budget Office will soon speak. The costs will be astronomical. Once Rahm Emanuel sees the poll numbers on health care reform decline--taking with it what's left of the President's standing on matters fiscal--Democrats will concede some political ground. They will roll into one bill whatever health legislation they can get done this year (a fix to the doctor fee schedule, expansions in Medicaid, follow on biologics, comparative effectiveness research, etc). They will proclaim it health reform. But it won't be what they started out to pass. Because in the end, they will have tried to deal Americans a bad hand.

Scott Gottlieb, M.D., is a resident fellow at AEI.

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