A Remarkable Interview: Obama on Healthcare

I hope you had a chance to read David Leonhardt’s interview with President Obama in last Sunday’s NY Times Magazine. The feel was that of hanging out with two really smart friends discussing the issues of the day over beers. What a treat!

In addition to Obama’s intelligence and forthrightness (with the exception of one dollop of purposeful disingenuousness, which I’ll get to later), I was floored by his personal knowledge of and passion for healthcare issues – particularly the increasingly contentious comparative effectiveness question (by the way, this week’s NEJM had several excellent pieces on CE – here, here and here).

In reading the interview, it was obvious that B.O. knows healthcare. In addition to his personal experiences caring for sick family members, Michelle’s job before becoming First Lady was VP for Community Affairs at the University of Chicago Hospitals. And Barak’s best pal is my old UCSF resident Eric Whitaker, who inherited Michelle’s old job at the U of C and was previously Illinois public health director.

On to the remarkable interview. David Leonhardt (truth in advertising: David is a good friend of mine) began the healthcare portion by asking whether medicine will be less paternalistic in the future. The President responded,

… we should not overstate the degree to which consumers rather than doctors are going to be driving treatments because… ultimately, he’s the guy with the medical degree… there’s always going to be an asymmetry of information between patient and provider. And part of what I think government can do effectively is to be an honest broker in assessing and evaluating treatment options…

Leonhardt probed Obama on how to handle treatments that cost money but don’t work:

…when [White House budget director] Peter Orszag and I talk about the importance of using comparative-effectiveness studies as a way of reining in costs, that’s not an attempt to micro-manage the doctor-patient relationship. It is an attempt to say to patients that… the blue pill, which costs half as much as the red pill, is just as effective, and you might want to go ahead and get the blue one… I actually think that most doctors want to do right by their patients.  And if they’ve got good information, I think they will act on that good information.

Obama goes on to cite the findings from the Dartmouth variations research (getting the data precisely right. Wow.):

… if it turns out that doctors in Florida are spending 25 percent more on treating their patients as doctors in Minnesota and the doctors in Minnesota are getting outcomes that are just as good – then us going down to Florida and pointing out that this is how folks in Minnesota are doing it… and are there any particular reasons why you’re doing what you’re doing? – I think that conversation will ultimately yield some significant savings and… benefits.

Leonhardt ends the discussion by asking the President about the toughest nut of all: end of life care. In recalling his grandmother’s last days, Obama frames the issues as smartly as I’ve ever heard them discussed:

…when my grandmother got very ill during the campaign, she got cancer; it was determined to be terminal. And about two or three weeks after her diagnosis she fell, broke her hip [probably from a mild stroke]. So now she’s in the hospital, and the doctors says, look, you’ve got about [3-9] months to live. [The doctor cautioned that her heart was weak and thus surgery entailed some real risks.] On the other hand, if you just sit there with your hip like this, you’re just going to waste away and your quality of life will be terrible.

And she elected to get the hip replacement and was fine for about two weeks, and then suddenly… things fell apart.

I don’t know how much that hip replacement cost. I would have paid out of pocket, just because she’s my grandmother. Whether… in the aggregate, society making those decisions to give… a hip replacement when [people] are terminally ill is a sustainable model, is a very difficult question. If somebody told me that my grandmother couldn’t have a hip replacement and she had to lie there in misery in the waning days of her life – that would be pretty upsetting.

I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicists… you have to have some independent group that can give you guidance… that’s part of what I suspect you’ll see emerging out of the various health care conversations that are taking place on the Hill right now.

Obviously, the President fully appreciates that some of the money to fund universal coverage must come from decreasing waste in the present system, which is driven by both perverse incentives and a dearth of data regarding what truly works.

But notice Obama the Politician at work. He knows full well that simply providing doctors in Florida information about how Minnesota docs practice ain’t gonna do the trick. (“Oh, really. Sure, now that I know about how they do things in Minneapolis, I’ll cut my cath volume by 30%!” I don’t think so.) He understands that, as I wrote recently, in order for comparative effectiveness research to liberate us from wasteful or ineffective care, the government (and other payers) must make some very tough, and controversial, calls.

The toughest issue of all, of course, is the one illustrated by Obama’s grandma, which he so eloquently describes.  And, embedded in his answer to the end of life question is, I’m pretty sure, his true thinking about how to make these hard choices. “You have to have some independent group that can give you guidance,” said the President in talking about end of life rationing. But that’s a pretty good description of the UK’s National Institute for Health and Clinical Excellence (NICE), which takes comparative effectiveness data and converts it into coverage decisions.

Do I blame him for soft-pedaling the endgame? No way. He is a pragmatist and has learned the Clintonian lessons about the dangers of too much specificity when it comes to overhauling healthcare. As the great Joe Klein observed in this week’s Time magazine, “The President has been clever about this… he hasn’t proposed a specific plan, allowing, instead, a proposal to percolate through the Congress.” Klein was also struck by Obama’s description of his grandmother’s hip in the Times interview. He writes,

This is the most sensitive health-care issue imaginable. But the question of whether the government can decide which health-care treatments are appropriate is central to whether an affordable universal system can be devised.

Precisely so. The President is playing this one perfectly, and in doing so might just succeed in healing our healthcare system, a feat that has eluded Presidents for three generations.

What a pleasure having a leader smart and savvy enough to make this possible. And congratulations to David Leonhardt for an interview that brought out Obama’s intelligence, deep knowledge of the issues, passion, and pragmatism.

7 Responses to “A Remarkable Interview: Obama on Healthcare”

  1. menoalittle May 11, 2009 at 5:17 am #

    Bob,

    Your post is insightful and eloquent, as is President Obama.

    The health care issues have been and remain well stated. However, the hypothetical differences in practice patterns and associated societal costs between docs in the oven and docs in the freezer will not be solved by comparative effectiveness scores of the treatments deployed. Give a few bucks for the differences in the average age of any states’ and regions’ populations and burdens of co-morbidities, but the solutions to the utilization dissonance between any two regions is found in Economics 101 and Economic History 101 which include lectures on supply and demand, wage and price freezes, and cost of living. It is not all comparative effectiveness, stupid (as the expression goes). The physician payment system needs creative adjustments. While Massachusetts is off to a start on this, theirs is too much like capitation.

    As for the cost of end of life care and of prolonging the dying process in cases of futility, much of this will be solved by all citizens having a living will (even if some want everything done) as part of the Medicare and Medicaid coverage. This was proposed to the Clintons in 1993 but guys like Newt were not interested (nor was Hillary, if she ever was given the documents). Wonder if President Obama sees the practical merits of this? A living will does not require much societal conversation and debate except from the politicians’ perceived political concerns.

    Then, getting to the basics on “comparative effectiveness”, it must be queried of the President and his financially conflicted HIT advisors; how can data emanating from HIT devices (CPOE devices, as an example) whose clinical and economic (look at the UK, and now, Australia) safety and comparative effectiveness is unknown, be deemed accurate?

    Best regards,

    Menoalittle

  2. geriatricdoc May 11, 2009 at 10:10 pm #

    The opinion of a nay sayer
    http://www.nytimes.com/2009/05/11/opinion/11krugman.html?em

  3. MKirschMD May 15, 2009 at 12:07 pm #

    It’s an easy task to attack comparative effectiveness research (CER). I could do it myself. Nevertheless, we need a mechanism to cull unnecessary medical interventions that do not help living breathing patients and are drowning the system financially. I support the objectives of CER vigorousy although I admit it will be a quagmire to define and measure effectiveness, particularly when the results, if implemented, could eliminate careers and companies. At present, I think the harder task is to defend a system that permits unlimited care for all. Look over the next emergency room record from any patient who has been there. The record will be littered with labs, CAT scans, EKGs, etc. If we saw the same patient in our office, we might have simply prescribed some Nexium.

    http://www.MDWhistleblower.blogspot.com

  4. menoalittle May 18, 2009 at 4:48 am #

    Bob,

    Relevant to your comments on President Obama’s passion for and knowledge of health care issues, is a report revealing the inner modus of the HIT industry, that appeared in the May 16, 2009, Washington Post:

    http://www.washingtonpost.com/wp-dyn/content/article/2009/05/15/AR2009051503667.html

    The knowledge proffered by this report reaffirms concerns and should give pause to those of us who are required to use medical devices that have not been approved for safety and efficacy and whose defects are kept secret by gag clauses in the contracts between vendor and hospital.

    Now we know that patients whose care is subject to these devices may be placed at even higher risk because the “research” results that do exist may have been influenced by the HIT industry.

    Thus, the premise of HIT as the foundation for health care reform is further called in to question. Is it not surprising, that someone as learned as our President, would not seek unbiased methodological scientific study of devices intended to radically alter medical care before their deployment?

    Best regards,

    Menoalittle

  5. jon weiss m.d. May 18, 2009 at 1:14 pm #

    bob ,was good to see u at the Penn reunion.just a few ques about the obama medical revolution-dont you think that medical malpractice concerns drive alot of wasteful testing and treatment (rather than the greed of florida cardiologists?)we must have tort reform on a grand scale before costs can be contained.also do you really think americans are prepared for the rationing to come?even the brilliant mr obama thought it was reasonable for terminally ill granny to have a hip replacement-now he plans to tell everyone else what their parent or grandparent can have-im afraid this will take a generation or two for all of us to realize that we cant live forever in good health.i see an awful lot of mri rexams in my practice on 80 yr olds with back pain for 20 yrs

  6. Bob Wachter May 23, 2009 at 1:08 am #

    Hi, Jon — good to see you as well at the Penn reunion.

    Sure, a significant part of the demand for expensive care is driven by patient expectations, and another chunk is driven by malpractice fears. The conundrum is that the only way around both of these drivers is to have “the system” tie our hands — although the 80-year-old patient with terminal cancer wants a hip replacement or palliative chemo, we simply can’t offer it because it is not covered. (Note that Obama says he would have paid for his grandma’s hip himself, which would be what folks would have to do if third party payers didn’t cover such things).

    Viz malpractice, adherence to a valid guideline would have to provide absolute protection against a malpractice suit — if the ED doc chose not to get a head CT on a patient who didn’t meet high-risk criteria and the patient turned out to have a brain hemorrhage, the doc would have to be completely shielded from legal action. Otherwise, defensive medicine will continue to drive oodles of unnecessary care.

    The point is that physicians are incapable of rationing at the bedside, and the system needs to support evidence-based decisions that conserve precious resources. Of course, the minute the system does that, all of the folks who have a stake in the old ways will accuse the new system as being “run by heartless bureaucrats” who are “taking the decisions out of the hands of doctors and giving them to green eyeshade-types.”

    This is one hell of a sticky problem, but one that needs to be addressed. Personally, I worry far more about overuse of unnecessary and non-evidence-based care, the impending bankruptcy of the Medicare Trust Fund and much of American industry, and 45 million uninsured people than I do about some limits (hopefully thoughtful ones) on my ability to offer certain types of high-end care.

    But ‘m a non-procedural generalist.

  7. jon weiss m.d. June 1, 2009 at 1:39 pm #

    AGREE WITH YOU BUT WILL THE PUBLIC AND POLITICIANS ACCEPT THAT THEY CANT SUE THEIR DOCS-MY GUESS IS THAT THE LAWYERS AND THEIR LOBBYISTS FEEL THIS IS AN INALIENABLE RIGHT.NOT TO MENTION THE HOWLING FROM THE PUBLIC ABOUT BEING DENIED ACCESS TO TESTING AND TREATMENT WHICH MAY NOT BE EVIDENCE BASED BUT IS PART OF OUR CONSUMER CULTURE.WE WILL NEED A GENERATIONAL MIND SHIFT AND INTENSE PUBLIC EDUCATION TO CHANGE THIS ATTITUDE-GOOD LUCK TO US ALL

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