Republicans and Ineffective Medicine

Incidental Economist noted an interesting story from a few years ago by Shannon Brownlee in the Washington Monthly, it is well worth reading in its entirety.  The gist of it is that there is very little research on the comparative effectiveness of medical treatments.  So when a doctor recommends treatment x, there is a good chance there is no scientific basis for saying that x is a better choice then treatment y.  The consequences of this can be horrific:

For example, surgeons long assumed that a radical mastectomy for breast cancer, removing not just the breast but the underlying chest muscle and the lymph nodes under the arm, was the only way to get every last cancer cell. Then a massive, multimillion-dollar clinical trial launched by the NIH in the 1990s found that lumpectomy with radiation was just as effective, not to mention less traumatic for many women. Many patients and doctors also fervently believed that high-dose chemotherapy was a woman's best hope when she had advanced breast cancer. The brutal regimen was used for twenty years before clinical trials finally demonstrated that it was no more effective than standard, far less punishing doses of chemo. During those twenty years, an estimated 9,000 women were killed not by their cancer, but by the high-dose treatment.

You'll need to read the story to understand all the reasons why we do so little research in comparative effectiveness, but one cause stands out because of its intentional character.  The first Bush administration created an agency that could deal with this problem, the Agency for Health Care Policy and Research (AHCPR).

Democrats and Republicans alike hoped that the AHCPR's research would help rein in costs by giving doctors better direction, and offering payers—especially Medicare—the ammunition they needed to make evidence-based coverage decisions. More significantly, the agency promised to improve the quality of health care by helping to ensure that doctors would give patients the treatments they really needed—and refrain from giving them care that could harm them.

Unfortunately, the agency did its job and released a study on back pain in 1994 that was unfavorable to back surgeons.  The surgeons got up in arms and found a champion on capitol hill in the new Speaker of the House, Newt Gingrich.  Although he failed in his goal of eliminating the agency, he succeeded in restricting its mission.  "Now, the AHCPR would merely be a 'clearinghouse' for data, which meant it could no longer offer Medicare explicit guidance when it came time to determine which tests, treatments, and procedures to cover." 

Simply put, Newt worked to keep healthcare stupid.  The consequences of that stupidity are obvious:  rampant price inflation, unaffordable premiums and increasing numbers of uninsured, and oh yeah, a bunch of guys who were rendered impotent and/or incontinent for no good reason.

You might think that this would be an issue given Newt's front-runner status for the Republican Presidential nomination, and in a different world it would be.  But in this world making healthcare stupid isn't exceptional for the Republican party, it is the rule.  Just look at the treatment of Don Berwick, Obama's nominee to head the Centers for Medicare and Medicaid Services.  He served a year under recess appointment before being filibustered out of office by Senate Republicans.  His awful crime?  You guessed it, promoting medical effectiveness. I won't even go into IPAB.

All of this leads to a question:  What is it about ineffective medicine that so appeals to Republicans?

Bartlett on Gingrich

Bruce Bartlett has a good op-ed in the NY Times on Gingrich's efforts to stupidify congress.  What struck me was the ending line:

It is essential that Congress not cripple what is left of its in-house expertise. Gutting the G.A.O. and abolishing the C.B.O. would be acts of nihilism. Any politician recommending such things is unfit for office.

Acts of nihilism are pretty much all Republicans can manage.  Consider the attempt to default on America's debt, or the intent to revoke health care reform without an alternative solution.  On too many fronts Republican ideas have been proven decisively wrong:  Lassez-faire markets and the wall street debacle, climate change and the increasing frequency of catastrophic weather events, trickle down economics and the most unequal society in living memory, the George W Bush administration...  Rather then acknowledge failure, Republicans resort to wholesale denials of reality and nihilism.  Gingrich isn't exceptional in his need to dumb things down, he is typical of the Republican party.

POW: Newt Gingrich

A new recommended podcast: Newt Gingrich speaking to a CFR crowd back at the end of April. It's probably the most intelligent discussion of foreign affairs I've heard from a credible Presidential candidate.

The major theme was about bashing government bureaucracies for failing to adapt to the faster information flows available. I can only imagine how chaotic federal departments are, I work in the private sector and that is bad enough. Newt brushes on the concept that engagement with the world whether in counter-terrorism, economic development, or even the foreign service requires integrating first and second gen Americans with readily available networks and language skills. It's easier to train a Pakistani to be a foreign service officer then it is to train a foreign service officer to be Pakistani. Sort of like the guy who said the FBI was terrible at combating the mafia until it hired Italians and Irish, and would be terrible at combating terrorism until it hired Arabs, Indians, Pakistanis, etc.

Not all was good. Gingrich peddles the war metaphor shamelessly. He manages to acknowledge that the war on terror is less then meaningful, but then he tries to reshape it into a war against Anti Modernity Muslims. Problem: Muslim terrorists aren't anti-modern. They're happy to use cell phones, the internet, and whatever other technologies suit their purpose. What they're against is a Western dominated modernity centered on America. Their problem is with the West, not with modernity per se. But acknowledging that means acknowledging the ways in which the West dominates modernity as experienced by Muslims, and Newt lacks the guts to go down that road.

Also, in answer to Newt's challenge about what religions besides Islam inspire terrorism, the short list is Hinduism and Buddhism in Sri Lanka, Hinduism in India, Protestantism and Catholicism in Ireland, and Judaism in Israel. The Hindu Tamil Tigers in fact invented the suicide bomb. Newt's real question is what religions inspire terrorism against the West, but if he put it that way it would again acknowledge there was something specific to the West that Muslims don't like.

Despite it's faults, the speech and subsequent questions are engaging. I strongly recommend.

PS: A fuller analysis of religion inspired terrorism can be found in a lecture by Robert Pape given to a UC Berkeley class on terrorism in 2006. He also wrote a book on the subject.