The Budget Debate We Should Engage

The upcoming presidential election has focused the national discussion on the budget and health care's role in driving our financial system off a steep cliff. Both sides have highlighted the importance of fiscal stability. President Obama's budget for fiscal year 2013 states, "We now face a make-or-break moment for the middle class and those trying to reach it... it is time to construct an economy that is built to last." Representative Paul Ryan, who rose to prominence when he presented the Republican alternative in the "Roadmap for America's Future," has argued for curtailing the growth of domestic discretionary spending and converting Medicare to premium support. But neither side has espoused a substantive, sustainable path to solvency.

Our budget imbalances are well-documented. Current federal debt is at 74 percent of the Gross Domestic Product (GDP), with annual federal deficits of 8 percent. Domestic discretionary spending, which encompasses education, welfare, and social programs, is currently at 4 percent of GDP, with both Mr. Obama and Mr. Ryan proposing reducing the burden to approximately 2 percent over 10 years. Economic models suggest that under the president's budget, by 2050, federal debt will rise to 124 percent of GDP -- clearly an untenable end.

Health care accounts for over 18 percent of GDP, more than twice defense (5 percent) and social security (4 percent) combined. By 2050, health care will consume a third of GDP, crippling the government's ability to deliver virtually anything other than medical care. As Victor Fuchs, the dean of health care economists, recently summarized, "If we solve our health care spending, practically all of our other fiscal problems go away. If we don't, almost anything else we do will not solve our fiscal problems."

Can we "solve" health care spending? The value of our health care investment is low. Quality of care is inconsistent, and life expectancy for those who have reached age 40 is short compared with other industrialized countries. The value problem persists because one-third of our health care resources are expended in the last year of life, often fecklessly. Delivering value-congruent care at the end of life by addressing goals with all patients (but denying care to none) decreases the cost of care by almost half, and improves life's quality without reducing its quantity.

The medical community can improve quality and cut costs by asking each patient what care he or she wants as death approaches, and delivering care consistent with each individual's wishes. Three reasons explain why we have yet to pursue this goal. First is sham outrage over rationing. We already ration care, but we ration irrationally. Some individuals undergo unnecessary, non-beneficial, potentially harmful procedures, while others do not access necessary preventive and chronic care. We can rationalize health care by informing each individual, assessing patient preferences, and personalizing the care we provide. Second, our system lumbers along with $2.3 trillion of inertia. Broad implementation of evidence-based medical practice typically takes 17 years; if Google were as nimble as our health care system, we would still be Asking Jeeves.

The medical community must make evidence-based, value-congruent changes broadly and expeditiously. Third, neither end-of-life counseling nor end-of-life care is routinely taught in medical school or residency. Our curricula reflect our priorities as a medical community, and we should value end-of-life care is at least as highly as DNA by teaching it to each trainee.

We know what thoughtful Medicare savings could fund. First, fiscal stability. Mr. Obama has met resistance to his proposals that would significantly curb Medicare spending, and Mr. Ryan's plan would cut benefits coarsely, without precisely targeting areas of waste. Second, investment in human capital. What if, rather than reduce discretionary spending from 4 percent to 2 percent, as both Mr. Obama and Mr. Ryan propose, we doubled it to 8 percent? Peer-reviewed, level 1 medical evidence has shown that investing in our community by ensuring that all children enter kindergarten healthy and ready to learn yields a dividend of seven dollars in benefits for every dollar spent. What would our long-term future hold if we invested in our people? Third, improved health for our population. If value were central to our health care choices, pediatricians would have time to check a child's report card, and family practitioners would screen all adults for depression; studies have proven those investments to improve health and happiness, yet we fail to prioritize them.

Alexis de Tocqueville, who revered American democracy, once explained to his French countrymen, "In the United States, things move from the impossible to the inevitable without stopping at the probable." We inevitably will address goals of care with all patients and liberate resources to invest in our community. How we make that move is the budget debate we should engage, and clinicians can lead where politicians have not.