It's easy enough to establish that Betsy McCaughey is lying. The stimulus does not do what she says it does. But there's a method to her mendacity. She's trying to get Democrats to disavow a bad thing that's a close cousin of a good thing. It's a nicely laid trap, and a good guide to the sort of attacks liberals can expect health reform to receive in the coming months.Go back to McCaughey's central charge: The stimulus contains provisions that "will monitor treatments to make sure your doctor is doing what the federal government deems appropriate and cost effective." That's not true, and isn't likely to become true. Here's what is true: Comparative effectiveness research, which the stimulus funds, could conceivably allow us to make smarter coverage decisions in the future. This isn't an alien concept: We know that prescribing a swift kick in the head doesn't cure gout. So we don't prescribe it. Nor do we offer antibiotics for cancers or knee surgery for eyeglasses for the flu. Those are easy calls. Deciding when an angioplasty or back surgery is appropriate is rather tougher. There's less evidence than you might think around these treatments, and much less evidence than you might hope demonstrating how these treatments compare to alternatives.So far as we know, about 30 percent of the health care we prescribe in this country is wasted. It doesn't do us any good. Cutting that down to, say, 10 percent, would mean huge savings, not to mention fewer unnecessary days in the hospital. Comparative effectiveness research aims to produce more of the sort of evidence that lets us make wise treatment decisions. (Electronic health records could be used to accelerate it because they would offer a lot of potential data to look through. It's not clear, however, that they would be used that way.)Providing better information for doctors is the sort of policy that could attain consensus in American politics. No one wants to pay for, or endure, a surgery they didn't need. But the Right is concerned about something different: They worry that the evidence provided will be used to make treatment decisions. This is what McCaughey means when she worries that the government "will monitor treatments to make sure your doctor is doing what the federal government deems appropriate and cost effective." To be sure, this would only apply, even in strong form, to federal programs like Medicare. Private insurers might or might not follow the government's lead. A more accurate phrasing to McCaughey's point: The government would decide whether or not to cover treatments based on whether research showed them appropriate and cost effective. McCaughey's demagogic genius is to make that sound like something new rather than something old. Medicare would not currently pay a doctor for grossly ineffective treatment (a flu shot for a staph infection, say). But it is true that more research would mean more of those decisions. In the absence of evidence, Medicare covers all manner of marginal treatments. When he was at the CBO, Peter Orszag liked to show this graph:
The Y axis is quality. The X axis is Medicare spending per beneficiary. There's no relationship. We're spending a lot of money we don't need to spend. More evidence would mean more decisions. The hope is that that graph would begin to take shape: More spending would associate with more quality. But that scares people. The people it most directly scares are the people who make money from Medicare's willingness to cover most everything: Pharmaceutical manufacturers and device manufacturers and surgeons of various sorts. The fight is over the very concept of evidence-based medicine. Health care, we know, is too expensive, and it's too expensive in part because we pay for lots of treatments that don't work. But every dollar of medical waste if also a dollar of manufacturer profit. And they -- and their allies on the Right -- will work very hard to keep those dollars. McCaughey is the populist attack against this data. The government will decide what is and is not covered! Well, if the government is your insurer, than it will, does, has, and within reason, should. But the lobbying attack against a higher-value, evidence-based system will come from industry. McCaughey and her anti-government hysteria is a sideshow here. The main opposition to a higher value, higher performing system will be the companies that stand to lose billions if we actually do cut down on waste and improper treatment.
The Y axis is quality. The X axis is Medicare spending per beneficiary. There's no relationship. We're spending a lot of money we don't need to spend. More evidence would mean more decisions. The hope is that that graph would begin to take shape: More spending would associate with more quality. But that scares people. The people it most directly scares are the people who make money from Medicare's willingness to cover most everything: Pharmaceutical manufacturers and device manufacturers and surgeons of various sorts. The fight is over the very concept of evidence-based medicine. Health care, we know, is too expensive, and it's too expensive in part because we pay for lots of treatments that don't work. But every dollar of medical waste if also a dollar of manufacturer profit. And they -- and their allies on the Right -- will work very hard to keep those dollars. McCaughey is the populist attack against this data. The government will decide what is and is not covered! Well, if the government is your insurer, than it will, does, has, and within reason, should. But the lobbying attack against a higher-value, evidence-based system will come from industry. McCaughey and her anti-government hysteria is a sideshow here. The main opposition to a higher value, higher performing system will be the companies that stand to lose billions if we actually do cut down on waste and improper treatment. 
