Kill the Rhinos! By DAVID BROOKS

July 24, 2009
Op-Ed Columnist
Kill the Rhinos! By DAVID BROOKS

Forget the wonkery. Let's get primeval. Rising health care costs are a stampede of big ugly rhinos. They are trampling your crops, stomping on your children's play areas and spoiling your hunting grounds.

President Obama wasn't exaggerating when he said this cost onslaught is unsustainable. The rhinos have been roaming unchecked for a generation. We've thrown research projects, legislative and corporate reforms at them, all in an effort to tamp down health care inflation. But the rhinos keep coming. They are ubiquitous, powerful, protean and inexorable.

They feed on fuel sources deep in our system: expensive technological progress, the self-interest of the millions of people who make their living off the system, the public's desire to get the best care for nothing, the fee-for-service payment system and so on.

The rhinos are closing off your future. As the White House folks say, health care premiums have doubled over the last decade. The government is saddled with $36 trillion in unfunded liabilities.

So your only question should be: Where do you find a tool or weapon big enough to stop the rhino stampedes? You know the problem is big, and you figure the response had better be gigantic.

Then you look on Capitol Hill and you see a bunch of popguns. The politicians describe these big ugly problems, but when it comes time to talk about their remedies they tell you: Don't worry. Nothing's going to change. In other words, we're going to eliminate the biggest, hairiest, most entrenched problem in the country without fundamentally changing the system and without asking for sacrifice from anybody.

Good luck.

Then you talk to the health care experts promoting the bills and they are very honest: We don't know exactly how to slow health care inflation. But we think we have some good ideas. We're going to put some innovations, information clearinghouses and pilot projects in this legislation, and over the next 10 years we will see what works to really bring down costs. We're going to go on a voyage of discovery to learn about rhino eradication.

And, indeed, some of the ideas do sound good: more information technology, comparative effectiveness research, conducting experiments to bundle hospital payments so they are based on outcomes. Some of the providers that do things right, like the Mayo Clinic, really are getting results.

But some of these ideas have been watered down in the legislation. And you're not a complete idiot. You know there is a big difference between finding islands of excellence and creating a national system based on them.

Besides, you've got a bunch of big, evil rhinos stomping around! You want more than some promising ideas to pinpoint waste, fraud and abuse. You want some big heavy hammers to clock those suckers in the head.

Now that the first wave of legislation is bogging down, you want to take the seeds of cost control and you want to do more. You want to eliminate or cap the tax exemption on employee health benefits. This is a big way to crush one of the core drivers of health care inflation. You're willing to give MedPAC-style technocrats a chance to take control of Medicare spending away from Congressional spendthrifts.

You want to loosen federal regulations so that states have more room to experiment — not tighten them, as the current legislation does, so that states have less. You want reforms throughout the system that will cut down on first-dollar reimbursement in exchange for catastrophic protection. You want to tie Medicare subsidies to income. You want to look at anything that will move us away from a fee-for-service model, the core perversion in the system.

You want to change incentives at both ends. The legislators who drew up the first bills want to change the provider's incentives. But big cost savings can also come if consumers have choices and incentives to hunt for cheaper coverage. The Wyden-Bennett bill gives people a chance to choose the best option, instead of imprisoning people in existing coverage, as the current legislation does. The Medicare Part D reform has produced impressive reductions by allowing consumers to pocket prescription drug savings. Other proposals would give people tax credits and allow them to go to any trusted community group — like AARP or a union or a religious group — that wanted to compete to offer coverage.

Not everything is compatible with everything else. But the point is that you have rhinos at the door! You'll try anything that works. You want a political class that no longer perpetuates the myth that people can get everything for nothing. You know that it was political pandering that got us into this mess in the first place.

Obama is right. Things will be bad if we don't tackle the problem this year. Things will be worse if we add to the costs without beating the rhinos.
Op-Ed Columnist - Kill the Rhinos! - NYTimes.com (2 August 2009)
http://www.nytimes.com/2009/07/24/opinion/24brooks.html?_r=1&sq=&st=cse&%2334;David%20Brooks=&scp=1&%2334;%20Rhinos=&pagewanted=print
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