American Healthcare Reform Agonistes

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Sylvan Lee Weinberg, MD, MACC, 4555 Southern Boulevard, Dayton, OH 45429. E:

I have invoked a bit of literary license in adding the epithet ‘agonistes’ to the title of this editorial. This is because the word agonistes was historically used following the name of persons who have struggled and suffered, and not as I have done to characterize the potential for struggle and suffering inherent in the radical proposals for changing America’s healthcare system now under way at our highest levels of government. As an aside, the classic and probably the original use of the word agonistes as an epithet was by the great English poet John Milton in his 1671 epic tragic poem ‘Sampson Agonistes’, which recounts the death of Sampson, a blind captive of the Philistines, as “Eyeless in Gaza at the mill with slaves.”

The chief actuary of the Centers for Medicare and Medicaid Services (CMS) has released a statement that the new Obama healthcare law will increase spending in the US beyond already unsustainable limits. However, major healthcare spending and full implementation of the program will not occur until 2014. That not withstanding, unless there is a change in the balance of power in the November congressional elections, a complete takeover of America’s medical enterprise by the Obama administration seems inevitable.

An ominous step has already been taken that is indicative of Obama’s philosophy of how America’s healthcare should be administered and controlled: the appointment of Dr Donald Berwick to head the CMS. There is no question that Dr Berwick’s professional, academic, and intellectual credentials are impeccable: he has a BA from Harvard College, a master’s degree from the Kennedy School of Public Policy, and an MD from Harvard Medical School; he is a Clinical Professor of Pediatrics and Health Policy at Harvard Medical School and a Professor of Health Policy and Management at the Harvard School of Public Health; he is widely published in medical literature; and he is President and CEO of the Center for Healthcare Improvement.

Based on his CV, it might seem that Dr Berwick is without question a superb candidate to head the CMS. However, there are other factors that cast serious doubt concerning his ultimate qualification to direct the CMS and the havoc he might wreak on access to and quality of American healthcare. Surely these questions must be raised based on his self-proclaimed admiration for the British National Health Service (NHS) and its draconian National Institute for Health and Clinical Excellence (NICE), which acts in part as the rationing arm of the NHS.

This is what Richard Smith, Editor of the British Heart Journal (BMJ), said in 2000 in an editorial about NICE, titled ‘The Failings of NICE’: “One failing of NICE is that it is living a double lie. The first lie, which is as is Orwellian as its name, is for NICE to deny that it is about rationing healthcare, which might be defined as denying effective interventions. Denying ineffective interventions is not rationing; rather it’s what Americans call a ‘no-brainer’.” Smith goes on to say that the second lie is to imply that if the evidence supports an intervention, it is offered, and without the evidence, it is not offered. He denies that it is so simple that these decisions can be made with some data and a computer. He contends, rather, that this lie corrupts the concept of evidence-based medicine, long championed by the BMJ.

Now, to get back to a review of Dr Berwick’s philosophies and how they would influence our access to healthcare, or lack thereof, in view of his avowed devotion to Britain’s single-payer and rationing-prone NHS and NICE, he is quoted as saying: “I am a romantic about the NHS: I love it. All I need to do to rediscover the romance is to look at healthcare in my own country. Any healthcare funding plan that is just, equitable, civilized, and humane must, must redistribute wealth from the richer among us to the poorer and the less fortunate. Excellent healthcare is by definition redistributional.”

Robert Goldberg, Vice President of the Center for Medicine in the Public Interest, writes on views expressed by Berwick at length in 2008: “Berwick complained that the American health system runs in the ‘darkness of private enterprise,’ unlike Britain’s ‘politically accountable system.’ The NHS is ‘universal, accessible, excellent, and free at the point of care—a health system that is, at its core, like the world we wish we had; generous, hopeful, confident, joyous, and just’: America’s health system is ‘toxic’ and ‘fragmented’ because of its dependence on consumer choice. He told his UK audience: ‘I cannot believe that the individual healthcare consumer can enforce through choice the proper configuration of a system as massive and complex as healthcare. That is for leaders to do.’”

However, as Goldberg points out: “It may not be joyous or configured correctly, but for nearly every disease, particularly cancer, stroke, and heart attacks, Americans live longer and healthier than do the English.”

Berwick has called Britain’s NHS “one of the greatest health institutions in human history and a global treasure” and said it sets an example for the US to follow. He is also enamored of NICE.

A Wall Street article by Scott Gottlieb titled ‘Congress Wants to Restrict Drug Access’1 notes that in Britain, a government agency evaluates new medical products before citizens get access to them. The agency has concluded that $45,000 is the most that will be spent on healthcare to extend a person’s life by one ‘quality-adjusted’ life-year. (By their calculation, a year combating cancer is worth less than a year in perfect health.) In the US, similar comparative effectiveness research will soon be under way, as discussed in some detail in an editorial in the winter 2009 edition of The American Heart Hospital Journal,2 along with some observations on the NHS and NICE, which unfortunately may soon be models for similar institutions in the US if President Obama and Dr Berwick have their way.

While my personal experience with the NHS is virtually non-existent, I have had one experience in England that may be pertinent to the current discussion. In the 1990s, when I was Editor in Chief of ACCEL, the American College of Cardiology’s international audio journal, we conducted interviews at the annual meetings of the British Cardiac Society. On those occasions we found it convenient to engage a British technician to handle the recording sessions. At his first session with us in the south of England, we noted that this man, perhaps in his early 60s, was walking with a limp and considerable discomfort. He said that he was on a waiting list for hip joint surgery. The next year, in the north of England, he seemed somewhat worse, but was still gamely carrying on. We asked him how long the waiting list could be—he just shrugged and went on with his job. Yet another year passed while he waited for surgery, obviously in pain but still gamely hanging on. This time when we asked, in disbelief, about the operation, he smiled and answered briskly: “Within a few weeks now.” At last he seemed at ease, and added: “But you know it won’t cost me anything.”

One can only admire British grit and toughness, but not Britain’s NHS and NICE, which can relegate a man in pain to more than two years without surgical relief. I cannot believe that this is the healthcare system that President Obama and Dr Berwick envision for America, but apparently it is.

In 1941 Winston Churchill said: “We have not journeyed across the centuries, across the oceans, across the mountains, across the prairies, because we are made of sugar candy.” No truer words were ever spoken. I have always been an Anglophile, but not for its NHS or NICE. If President Obama and Dr Berwick succeed in molding American healthcare in the image of Britain’s NHS and NICE, American healthcare reform agonistes will become our reality.

  2. Weinberg SL, The Perils of Government Controlled Comparative Effectiveness, Am Heart Hosp J, 2009;7(2):78–81.