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People who participated in the Obamacare debate recognized that the bill would set up government panels to determine what illnesses had to be covered by every medical insurance plan in the land. Sarah Palin realized that the panels would also determine who would get treatment and who wouldn't, named them "death panels," and shifted the terms of the debate.
There hasn't been as much talk about the other panels that would try to determine the most effective treatment for any and all diseases. These committees would specify what treatments would be available for any given illness and what treatments couldn't be offered. If the treatment didn't work for you, too bad! You'd been treated, by definition, you were well, and you'd be told to quit bellyaching.
Fortunately a controversy blew up over mammograms which illustrated the difficulties in determining the best medical treatment. Mammograms have been around for a long time and reams of data have been collected. When a panel tried to recommend that women not start getting mammograms until age 50 instead of starting at 40, women who'd been told for years to have an annual mammogram were incensed that their mammograms would no longer be paid for by insurance and that they'd have to pay themselves if they wanted mammograms out of season.
This argument illustrates the difficulty of orchestrating who gets what medical treatment. Up until now, such decisions have been made by doctors in consultation with their patients. Our ruling elites have determined that this approach costs too much and doesn't give them the power they deserve, so they want to have a panel write treatment standards that have the force of law.
Women have been giving birth even longer than they've been having mammograms. Boston Lying-In Hospital was founded in 1832 to care for women who couldn't afford in-home births. You might think that nearly two centuries of data-collection would give us a decent consensus on how to deal with pregnancy, labor, and childbirth, but you'd be wrong.
The New York Times reported on the Tuba City hospital whose staff take pride in a higher-than-average rate of vaginal deliveries. Their staff perform far fewer Caesarean sections than comparable facilities. The patients don't have a lot of money and the doctors are insured by the federal government, so the usual economic forces don't apply as strongly. The Times explained that Tuba City "somehow manages to outperform richer, more prestigious institutions when it comes to keeping Caesarean rates down, which saves money and is better for many mothers and infants."
The big debate is about vaginal birth after Caesarean, or VBAC. The difficulty with VBAC is that once you cut the uterus open far enough to take a baby out, the skill with which the cut is sewn up has a great deal to do with whether the uterus is strong enough to deliver a later child. If the cut doesn't heal strongly enough, the uterus can tear which can be fatal to the mother.
The national Caesarean rate, 31.8 percent, has been rising steadily for the last 11 years and is fed by repeat patients. Critics say that doctors are performing too many Caesareans, needlessly exposing women and infants to surgical risks and running up several billion dollars a year in excess bills, precisely the kind of overuse that a health care overhaul is supposed to address. [emphasis added]
Even the American College of Obstetricians and Gynecologists has acknowledged that the operation is overused. Though there is no consensus on what the rate should be, government health agencies and the World Health Organization have suggested 15 percent as a goal in low-risk women.
Thus the consensus is that American mothers receive Caesarean surgery about twice as often as necessary. The rule used to be, "once a Caesarean, always a Caesarean." Back in 1980, an expert panel declared that VBAC was safe under certain circumstances. By 1996, 28.3 percent in women with previous Caesareans were delivering vaginally.
Then there were a few ruptures, some deaths, and the usual lawsuits. The VEBA rate has fallen below 10%.
The big difference at Yuba City is that most births are attended by nurse-midwives who don't make any money if the mother has to have surgery. In the rest of America, midwives handle only about 10% of the births.
Dr. Amanda Leib, the director of obstetrics and gynecology at Tuba City, said: "I think the midwives tend to be patient. They know the patients well, and they don't have to leave at 5 to get home for a golf game or a tennis game. As crass as that sounds, I do think it has some influence."
The doctor's convenience certainly plays a part. The problem with letting babies be born when they're ripe means that more than 2/3 of all births will happen outside normal business hours. A doctor gets paid extra for inducing a birth, which increases the probability that the baby will be born before tee-time.
Doctors have been known to insist on Caesareans if the baby didn't come soon enough for them to leave at the end of the day. The fact that doctors get paid more for Caesarean deliveries than for vaginal deliveries never enters their minds, of course.
Mammograms and giving birth have been around a long time and we still can't work out reasonable policies.
Wasting money on unneeded, risky medical procedures isn't just a women's issue; it affects men as well. The Times reports that the health care system wastes billions on inaccurate tests for prostate cancer. As with mammograms, false positives lead to very expensive, and very profitable, follow-up tests. If only the government were wise enough to decide between necessary and unnecessary treatments without annoying the trial lawyers who support them, we'd be home free!
One of the biggest flaws in Obamacare is the assumption that the government can direct all the various players in the system from a central podium in Washington. A few minutes googling shows that at 1/6 of the American economy, our health care system is about the size of the entire Soviet economy at the time the Berlin Wall collapsed.
The Soviet bureaucrats tried to run the economy in a top-down fasion - they'd plan how many shoes to make, how many socks, and how many tubes of toothpaste. They'd also set prices for everything, just as Obamacare plans to do for the entire health care system. Unfortunately, they never got it right. If they set prices too low, supplies ran out. If they set prices too high, unusable stuff piled up in the warehouses.
Unlike the New York Philharmonic, which responded instantly and eagerly to the slightest twitch of Leonard Bernstein's baton, out health care system is far too complex to be orchestrated from Washington. We can't agree on how often women should have mammograms even though we've been giving mammograms for decades. We've been delivering babies by Caesarean section for two thousand years and we can't agree when women should deliver vaginally and when they shouldn't. The only way to manage a market of that complexity is for the government to get out of the way and let people spend their own money.
Please, Maestro Obama, you can't possibly orchestrate our health system. Have a little humility!