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Nobel Laureate: Docs Must Insist on Evidence in Medicine

NEW YORK CITY — Doctors should demand more research into evidence-based treatments, Paul Krugman, PhD, Nobel laureate in economics, said here.

“We’re remarkably ignorant about what works in medicine, and that’s something doctors really should be demanding, that we have much more evidence-based treatments,” Krugman, who is also professor of economics at the City University of New York, said Tuesday at an event sponsored by the New York Academy of Medicine. On the other hand, when it comes to healthcare reform, “Doctors should be doing medicine, not economics, and we should aim for a system where they don’t have to.”

Krugman was joined onstage by Tsung-Mei Cheng, JD, a health policy research analyst at Princeton University in New Jersey, and the widow of the late health economist Uwe Reinhardt, PhD. The two were there to commemorate the publication of Reinhardt’s final book, Priced Out: The Economics and Ethical Costs of American Health Care.

“I’m a big proponent of following evidence-based clinical guidelines and even clinical pathways,” said Cheng. “If doctors could adhere more to evidence-based clinical guidelines, that would be a big help, because we have too much variation.”

Paul Krugman, PhD, City University of New York (Photo by Joyce Frieden)

A Long Time Coming

“Uwe wanted to do a book like this for a very long time,” said Cheng. “It really is necessary to explain our national health policy, which is a bundle of confusion and contradiction … He thought it is important that the public and policymakers learn as much about the healthcare system [as possible] based on facts and evidence, for the good of our democracy.”

Reinhardt was worried about two troublesome trends, Cheng said — “the rapid growth in the cost of American healthcare in the face of the growing inequality in the distribution of income and wealth in our country,” she said, and added a quote from the book: “Over time these two combined to price a growing number of American families out of the high-quality — or at least luxurious — American healthcare that families in the higher strata of the nation’s income distribution would like for themselves. We have now reached a pass where bestowing on low-income Americans even standard medical procedures such as a coronary bypass or hip replacement is the financial equivalent of bestowing on a poor person a fully loaded Mercedes Benz.”

Cheng listed some numbers to illustrate the high cost of American healthcare. “We spend 17% of GDP when in the OECD [Organization for Economic Cooperation and Development] countries, the average spending is 8.8% … All of these other countries have universal healthcare, but in America we have 8.5% of our population without health insurance today,” which is up from 2017. In addition, “per capita health spending in the United States in 2018 is $10,586 where the OECD average is just below $4,000.”

When considering the median household income in America, “45% of that household’s money goes to pay for the cost of healthcare,” she continued. Data from the Centers of Medicare & Medicaid Service (CMS) and the Congressional Budget Office (CBO) show that healthcare spending over the next 10 years is expected to increase at 5.5% per year, compared with an average annual increase of 1.8% in the Gross Domestic Product (GDP).

An Ethical Question

Reinhardt was getting increasingly frustrated about a troubling fact in the healthcare reform debate, said Cheng. “That [is] that the debate about health reform in the U.S. is conducted in a jargon of economics and constitutional federal/state relations, but it’s not really about economics and the Constitution at all.” Instead, it’s really about “distributive social ethics: to what extent should better off members of society be made to be the keepers of brothers’ and sisters’ healthcare?”


Tsung-Mei Cheng, JD, Princeton University (Photo by Joyce Frieden)

Krugman noted that the first step in healthcare policy “is a choice of values: to what extent should your socioeconomic status determine your access to healthcare?”

“One consistent position is that it shouldn’t matter … The really important stuff should be a right and everybody should get it,” he said. “The other position is, life is full of unfairness, we don’t all get to live in big houses with great views, we don’t all get to drive Mercedes Benzes, and we don’t all get to have lifesaving operations. That’s a philosophically consistent view, that freedom is the freedom to do what you want with your money and nobody has the right to make you pay taxes to subsidize someone else’s lifestyle, including their life, through healthcare.”

“There are a fair number of people who probably believe that, but no one in political debates is ever willing to admit that, so what you get in our actual political debates is an enormous amount of double-talk,” he added.

Support for a Public Option

Both Cheng and Krugman said they opposed a Medicare for All system and instead favored a public/private system with a public option. “I have to say that I think of Medicare for All as not really an economic debate, because it’s not going to happen,” said Krugman. “You could have a President [Bernie] Sanders or a President [Elizabeth] Warren and a Democratic Senate majority and there still won’t be the votes for Medicare for All.”


(l-r) Tsung-Mei Cheng, JD, Princeton University; Paul Krugman, PhD, City University of New York (Photo by Joyce Frieden)

“I think the public option is really the way to go because you’re really allowing the market to work,” said Cheng. “The public option can use its pseudo-monopolistic power to negotiate better practices, and will cause private insurers to look at their own prices to be competitive with the public option, and there will be savings across the board.”

During a question-and-answer session, Oliver Fein, MD, a practicing internist, chair of the local chapter of Physicians for a National Health Program, which supports a single-payer healthcare system, said he was disappointed at the emphasis Cheng and Krugman placed on political feasibility. “It’s important for people to stand up ethically for what will make a difference,” said Fein. “For-profit health insurance will totally try to destroy the public option. How will you save money when you have a multi-payer system that will destroy the public system?”

Krugman disagreed. “It could sound principled to say ‘Let’s disregard the politics,’ but if it leads to not actually getting anything, then it’s not helpful,” he said. “People I respect have very varied feelings about the Affordable Care Act, which … is a Rube Goldberg device in a way that no one starting from scratch would have done anything like it.” And yet, he continued, “it got 20 million people healthcare coverage who would not have had it otherwise, and it was the maximum thing that could have been passed in 2010. In 2021, hope we’ll be able to do something more, but it won’t be the perfect system even then.”


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