This is our third and last post examining the question of whether it’s possible to mitigate the actual harm that government control of healthcare is likely to entail.  In our first post on the topic, we established that government is perfectly capable of botching up just about anything.  In the second post we looked at the rapidly expanding role of unfettered government bureaucracy, as well as some very convincing arguments that it now constitutes an entire independent fourth branch of government unto itself.  What we’ll explore in this post is whether it’s possible to limit the damage that is frequently done by Congress itself.

Legislators are the elected representatives of the people.  One problem with that is that they’re frequently not experts at anything other than how to get elected.  This has serious implications for Congressional control of any industry, but especially a diverse, highly complex and scientifically based industry like healthcare.  First, it means that legislators must generally rely on others to influence (or even make) their decisions.  These “other parties” typically include staffers, lobbyists, spouses and special interest groups – hardly a guarantee of sound and carefully considered policy.  Second, it increases the likelihood that legislators try to address symptoms rather than actual problems themselves.  We saw this in a myriad of ways with the Accountable Care Act (the “ACA, or “ObamaCare”).  Just one circular example:

Symptom:  People don’t have access to healthcare services.

Solution:  Give them Medicaid, even though fewer and fewer doctors can afford to take it.

Symptom:  Doctors can’t afford to see Medicaid patients.

Solution:  Raise payments to providers for two years as more people are added to the Medicaid rolls, then lower them back to previous levels.

Symptom:  We can’t afford Medicaid.

Solution:  Cut payments to providers still further.

Anyone can see that all of this reacting has accomplished exactly nothing except to generate a lot of additional expense and dashed expectations.  There is little or no understanding that healthcare is an ecosystem.  You can’t just tweak it here or there and expect there not to be adverse and undesirable consequences.

As nearly as we can tell, there are three possible solutions to the dilemma of unsophisticated legislators: (1) elections that yield better candidates, (2) education and (3) the scientific method.

We’re going to rule out the idea of routinely electing people who have a great deal of intelligence, knowledge, skill and expertise right away.  This is, after all, still planet Earth and we’re talking about the election behavior of homo sapiens.  So we might as well take it as a given that the quality of our elected officials is not about to improve anytime soon.  That leaves education and the scientific method as the only tools available.

Educating our elected representatives to a level that’s high enough to allow them to make good decisions about healthcare is certainly a challenge.  Legislators are routinely asked to weigh in on topics ranging from whether bombing Libya constitutes “hostilities” to whether chickens ought to be raised in cages.  It’s obviously unrealistic to expect them to learn a substantial amount about all of these topics; thus the division of research sessions called “hearings” among hundreds of different committees and sub-committees.  Committee members are supposed to become experts on the topics they cover and then recommend bills to their legislative colleagues.  They may or may not succeed in this regard, but even this doesn’t solve the basic problem of topical ignorance – the vast majority of representatives will ultimately be called upon to vote about things they know little or nothing about.*  This renders the debates that take place on the floors of the House and Senate as the last possible opportunities to educate our representatives before the vote.  But this simply raises another problem.

Question: who are the people speaking in these debates?

Answer: the representatives themselves, most of whom know little or nothing about the issue under consideration and whose arguments need not contain any factual information.

In practical terms it’s not much different from asking a class of fourth graders learn history, math and science by all sharing what they know or may have heard on television or around the dinner table.

As it happens, one potentially useful way to deal with this problem would be to take a lesson from God, (well, from the Vatican, anyway), in the form of a “devil’s advocate”.  What’s a devil’s advocate?  We don’t often quote Wikipedia, but this post seems to be pretty accurate:

“During the canonization process of the Roman Catholic Church, the Promoter of the Faith (Latin: promotor fidei), popularly known as the Devil’s advocate (Latin: advocatus diaboli), was a canon lawyer appointed by Church authorities to argue against the canonization of the candidate. It was their job to take a skeptical view of the candidate’s character, to look for holes in the evidence, to argue that any miracles attributed to the candidate were fraudulent, etc. The Devil’s advocate opposed God’s advocate (Latin: advocatus Dei; also known as the Promoter of the Cause), whose task is to make the argument in favor of canonization. This task is now performed by the Promoter of Justice (promotor iustitiae), who is in charge of examining how accurate is the inquiry on the saintliness of the candidate.

The office was established in 1587 during the reign of Pope Sixtus V and abolished by Pope John Paul II in 1983. This reform changed the canonization process considerably, helping John Paul II to usher in an unprecedented number of elevations: nearly 500 individuals were canonized and over 1,300 were beatified during his tenure as Pope as compared to only 98 canonizations by all his 20th-century predecessors, which has led many to question the validity of the process and whether all of those canonized today are deserving of the recognition. Such a dramatic increase suggests that the office of the Devil’s Advocate had served to reduce the number of canonizations. It is argued that it served a useful role in ensuring that canonizations did not proceed without due care and hence the status of sainthood was not easily achieved. In cases of controversy the Vatican may still seek to informally solicit the testimony of critics of a candidate for canonization. The British-American columnist Christopher Hitchens was famously asked to testify against the beatification of Mother Teresa in 2002, a role he would later describe as being akin to ‘representing the Evil One, as it were, pro bono’.^”

One can see this immediate appeal of this approach as applied to legislation and the education of our legislators.  Two independent and unbiased (in that they have no vested interest one way or another) experts would be appointed to carefully review each piece of legislation on their given topic.  One would act as an advocate, while the other would act as a devil’s advocate.  Each would speak in factual terms for a given period of time that would be proportionate to the relative importance and size of the legislation.  A legitimate explanation of legislation as massive as the ACA might take weeks or months, enough time to perhaps prevent its passage on the basis of sheer size and complexity alone.  The explanations and arguments posed by both advocates can and should be widely televised.  You can readily imagine that the result would be very similar to that obtained by the Vatican – far fewer laws, especially marginal ones, are likely to get through.  And after a little public humiliation, there’s a good chance that the laws that are proposed would be shorter, better crafted.  Attempts at earmarking and political chicanery would broadcast far and wide for the world to see.  Hallelujah and Amen!

So this is a great idea, but it’s clearly unlikely to happen.  After all, if Pope John Paul II eliminated the position of Devil’s Advocate after it had been in use for nearly 400 years just so he could go on a sainting spree, what chance does Congress have of weaning itself off of lobbyists, earmarks and legislation based upon good policy rather than good politics?  That leaves us with one final alternative: science.

Earlier this year, Ben Goldacre’s “Bad Science” blog had an interesting post entitled “We Should So Blatantly Do More Randomised Trials On Policy”.  In it, he pointed out that the world of randomized controlled trials (RCTs)was not necessarily limited to science and medicine, but had proven real-world applications in many areas of social, economic and public policy:

“Randomised trials are our best way to find out if something works: by randomly assigning participants to one intervention or another, and measuring the outcome we’re interested in, we exclude all alternative explanations for any difference between the two groups. If you don’t know which of two reasonable interventions is best, and you want to find out, a trial will tell you.

Microfinance schemes help small producers buy in bulk to make larger profits, and they change lives. But are group-liability loans better, because people default less, so the project is more sustainable? Or do anxieties about shared responsibility restrict recruitment? Some academics ran a trial.

Do free uniforms improve school attendance, especially in pupils who don’t own one at all? Someone ran a trial. Contingent payments improve attendance: but what’s the best time to pay, and how? There’s another trial. What about streaming in Kenyan schools, with high and low ability classes? Do all kids do better? Someone ran a trial. Maybe different strategies to encourage saving work best in different places? Innovations for Policy Action ran a series of trials to find out, in the Philippines, in Bolivia, in Peru.

I won’t tell you the results, for any of those projects: because this isn’t about good news on what works, or bad news about what doesn’t. What matters is that someone ran a randomised trial and found the answer…

…So here is my fantasy. We sack the Behavioural Insights Team – all they’ll do is overextrapolate from behavioural economics research – and open a Number Ten Policy Trials Unit instead.

They sit down to write a giant list of unanswered questions, for situations where we don’t know if an intervention works: this will be most of them. Then we filter down to questions where a randomised trial can feasibly be run. Then we do them.

This won’t cost money: it will save money, in unprecedented amounts, by permitting disinvestment in failed interventions, and it will transform the country. It’s efficient, it’s sensible, and it will never happen, because politicians are too ignorant of these simple ideas, too arrogant to have their ideologies questioned, and too scared – let’s be generous – of hard data on their good intentions.”

Readers of this blog already know that the Road to Hellth is paved with plenty of good intentions, so Goldacre’s fantasy for Britian is just as intriguing here in the USA.  Imagine if, instead of implementing the current Resource-Based Relative Value System (RBRVS) across the land by legislative fiat back in 1992, Congress had instead mandated the creation of one or more RCTs focused on the optimal means of paying clinicians for seeing Medicare patients.  One arm would have retained the payment method in existence at the time.  A second would have implemented the highly complex RBRVS that currently afflicts American healthcare.  A third might have included some trial of HMOs, as “Accountable Care Organizations” were known at the time.  Finally, a fourth arm would have implemented a simple program of paying doctors for their time on an hourly basis as we’ve described previously.  The endpoints evaluated by this study would have included measures of the total burden of costs imposed on the healthcare system, ease of implementation, patient and clinician satisfaction, access to care and relevant data regarding the quality of care provided for certain important diseases.  Under these conditions, we believe that there is no way that the RBRVS system would have proven itself suitable for widespread use, nor would HMOs/ACOs have been shown to be economically and clinically viable.  Billions, and even trillions of dollars might have been saved on behalf of Medicare, physicians, businesses patients and taxpayers.

But here again one has to ask: “Is there any reason to believe that legislators in general, and the U.S. Congress in particular, are willing to exchange real science, real data and the real world for the wooing of lobbyists, the lure of political expediency and the siren song of good intentions?”  Hardly.  Ours is a political world in which Mitt Romney contends that the healthcare program he initiated in Massachusetts and the ACA bear no resemblance to one another, and President Obama seriously claims that his healthcare reform legislation will cost less than $1 trillion.  Where’s the evidence that the real world and real facts matter to these people?

Which brings us to the heart of the matter.  Can rational people ever be comfortable with government control of healthcare through a “single payer” system, knowing that the legislative system of representation is characterized by – and we mean this in the kindest possible way – ignorance, manipulation, short-term thinking, political tribalism and the urge to act in the absence of the facts?  Especially when we know that the laws passed will then be administered by unaccountable bureaucracies?  It’s a risky business, made riskier by the unlimited authority of government punish those with whom it disagrees.  And although there are tools that can be used to mitigate the risk, it would be wise to implement these and gauge their effectiveness in a less important realm before putting the government in complete control of nearly one-fifth of the economy.

Given our recent track record of good governance, anything else is just playing with dynamite.

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*The problem is made still worse by deliberate measures taken to ensure that legislators don’t even know what they’re voting on.  In the case of the ACA these included voting on an absurdly large 2,400 page bill before anyone had time to read it, prompting Speaker Nancy Pelosi’s famous remark that it had to be passed “so you can find out what’s in it”.