Opinion

KOLB: The Health Care Issue Candidates Are Ignoring — Who Decides When Coverage Is Provided?

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Charles Kolb Deputy Assistant to George H.W. Bush

Polling suggests health care is the most important issue today. As the 2020 presidential election nears, there are basically three health care-reform approaches on the table: (1) Trump’s and the GOP’s promised but as-yet-to-be-announced proposal, (2) the Sanders-Warren “Medicare-for-all” proposals, and (3) Biden’s let’s-improve-upon-Obamacare proposal. The debate is mostly about total cost, how we pay for coverage, and how much access to coverage will be provided.

What’s missing is any serious discussion of what’s going to be covered under each approach. The presidential candidates in both parties are not addressing the question of who decides what procedures and medicines will be covered. The real issue is not just about “access” but “access to what”?

With an aging population (an estimated 10,000 baby boomers are retiring each day) plus new and costly advances in medical technology, procedures, and pharmaceuticals, the nation faces the prospect of deciding who gets what in this emerging medical smorgasbord.

The good news is that progress is being made on several medical fronts; the bad news is that we will not be able to afford all of these new treatments. Left unresolved today is who will decide the access-to-what questions.

According to the Centers for Medicare and Medicaid Services, U.S. health care costs as of 2017 reached 17.9 percent of GDP and are projected to hit 19.4 percent by 2027. We also spend more per capita on health care than most other developed nations but with relatively paltry results when measured by outcomes such as infant mortality, longevity, obesity, and preventive care.

In the United Kingdom, these access issues are handled by a National Health Service group known as NICE: the National Institute for Health and Care Excellence. During the Obama years, when similar questions arose here and a similar approach was proposed, former GOP vice-presidential candidate Sarah Palin labeled the approach as creating “Death Panels.”

We can hype and politicize these issues all we like, but at the end of the day, somebody has to pay for the medical care provided. That somebody is the American taxpayer.

Take Alzheimer’s disease, the costs of which include not only the treatments provided to the patients but also the costs of care provided by families and partners (including time away from work), insurance companies, and government. Are we going to provide whatever costs are necessary to treat Alzheimer’s patients?

Given the projected demographics and costs associated with greater longevity, I’d welcome a presidential candidate who prioritized a JFK-type “moonshot” program to find a cure for Alzheimer’s disease in the next decade.

Take the issue of “orphan drugs,” pharmaceuticals that treat a relatively small number of patients but which are not profitable and therefore require government subsidy or assistance. One such example is a treatment for spinal muscular atrophy, Spinraza, whose costs can reach $700,000 annually. Will this medicine be available to anyone on demand?

Our political leaders need to be leading this discussion with details rather than slogans. If we approach health care the way we seem to be approaching every other significant budget issue by spending whatever it takes, we will drive the national debt to levels that will bankrupt the country in relatively short order.

Massachusetts Sen. Elizabeth “I Have A Plan” Warren’s website offers an interesting but vague set of solutions to health care issues. She pledges “a guarantee of high-quality health care” plus a commitment that “[n]obody goes broke because of a medical bill.” Additionally, everyone will receive “adequate mental health benefits.”

Warren’s bottom line sounds just great: “Every American should be able to get the care they need when they need it” because health care “is a basic human right.” Sign me up; I’m a boomer!

But missing from Warren’s plan is any discussion of structural reforms or the necessary incentives that will move the American health care system toward promoting value over volume.

The real public-policy debate is how to encourage investments that will yield medical breakthroughs while also providing access to affordable treatments that will benefit most Americans. Simply announcing that we will soon have “free medical care” just as we will have “free college for all” is not an answer.

The country must address these challenges sooner, not later. We also need leaders who go beyond vague, feel-good pledges and who are willing to engage the country in a debate about how to decide among competing priorities.

There just aren’t enough billionaires to tax to fund Warren’s commitments.

Charles Kolb was deputy assistant to the president for domestic policy in the George H.W. Bush White House from 1990-1992. From 1997-2012, he was president of the nonpartisan, business-led think tank, the Committee for Economic Development.


The views and opinions expressed in this commentary are those of the author and do not reflect the official position of The Daily Caller.