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Defending "My Drug Problem"

The Atlantic
By Virginia Postrel
March 30, 2009

Before embarking on this new discussion, I hope readers will read (or re-read) my original article, since the more emotionally and politically charged the subject, the more likely letter writers are to respond to something different from what appears on the page. Thus, in the minds of some readers, my cautionary tale about the tradeoffs involved in centrally controlling drug costs, told in part through the story of my own experience with the cancer drug Herceptin, became a brief for a particular health-care system—in this case, the status quo. And an article informed by a mountain of studies on Herceptin, drug-pricing, and treatment diffusion, as well as considerable reporting, was attacked for relying solely on personal anecdote.
 
On the first point, let me clear up a couple of misconceptions. Like any patient, I have many complaints about the current system. I, too, have wasted time convincing my insurer to pay bills for procedures obviously covered under my plan. I, too, have been bewildered trying to reconcile the strangely different ways in which medical center billing departments and the insurer classify exactly the same expenditures. And, of course, as a patient with a pre-existing condition who has in the past been happily self-employed, I am acutely conscious that my own options are now more limited than they once were.
 
Before my personal experience as a patient, I objected to the delivery of health insurance through employers, as many economists and policy analysts do. Employer-based health insurance unduly limits the flexibility of Americans to change jobs, work part time, or start businesses and amplifies the negative repercussions of an economic downturn like the one we’re now experiencing. I also know that the current system of reimbursement, led by Medicare, has taken a terrible toll on primary-care physicians in particular, driving many out of medicine and requiring others to skimp on care (spending little time with patients) or develop cosmetic side-specialties (Botox, anyone?) to subsidize their practices.
 
But acknowledging that the current system has problems and might be improved is a long way from believing that those problems can be solved simply—or that Americans can have, as many readers seem to believe, health care that is simultaneously cheaper, less likely to escalate in cost, more widely available, technologically innovative, and fully responsive to the desires of patients and physicians.
 
Wiping out administrative costs, often cited as an advantage of centralized health-care systems, might reduce the cost of care to a lower level, but those costs would continue to rise. The growth of medical expenditures in the U.S. is not caused by administrative costs but by increases in the technical intensity of care over time—a.k.a. medical progress. The technocratic magic of “scrutiniz[ing] new treatments for effectiveness,” as described in a January New Republic article, could limit cost increases only by denying patients some of the care they want and by blocking the adoption of newer and more expensive treatments. We know that Americans hate such limits. As a former aide to a Democratic congressman commented in response to my article:
 
Personally, I think people have very short memories on this debate. It was maybe 10–15 years ago that everyone was up in arms about the possibility of HMOs denying certain treatments or procedures, and managed care got a huge black eye. We had a national debate about whether you could sue your HMO for not allowing certain diagnostic screening procedures. Now, we’re really talking about the same type of denial of certain procedures, but the roles are reversed; huge chunks of the Democratic Party want the limits now, and the Republicans are saying no way, everything should be allowed.
 
In the early 1990s when patients objected to the limits of managed care, employers responded by shopping around for more generous plans and insurers became somewhat more lenient in defining coverage. Along with competitive pressures, lawsuits and state mandates also forced broader coverage. (Controversy currently surrounds coverage for autism treatments, which make the priciest cancer drugs look cheap by comparison.) The big difference between a centralized system and a competitive one is the speed with which adjustments can be made. In addition, private businesses are generally more easily sued and more subject to political regulation, especially at the state level, than a government health plan would be.

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