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.