Who Is The Expert on Essential Services?

Who should be making your medical decisions? Your doctor? Your insurance company? The federal government? Your employer? A board of experts? Artificially intelligent agents? You?

Under the Patient Protection and Affordable Care Act (ACA), the federal government will dictate coverage through its control over what services are included in a minimally acceptable health insurance policy that everyone is required to carry.

Right now, the Obama administration is trying to devise a list of what those "essential services" are. It's finding the going pretty tough. After the flare up over the mandatory provision of free contraceptives, don't expect to hear a lot of announcements before election day about which services will or will not be covered.

The federal government has tried to punt that decision back down to the states, but it's clear that if the states come up with a basket of services the U.S. Department of Health and Human Services considers inadequate, the federal government will assert its authority. And the House of Representatives has already voted to repeal the IPAB board, the super-panel that will tweak the essential-services basket and whose decisions cannot be overturned by Congress.

In The Wall Street Journal's critically-acclaimed Review section, two Harvard Medical School doctors explain why there can be no  "best practices" solution to medical questions that does not take into account the patient. Pamela Hartzband and Jerome Groopman challenge the theory that one set of medical practices can be adopted in any universal fashion:

Policy makers need to abandon the idea that experts know what is best. In medical care, the “right” clinical decisions turn out to be those that are based on a patient's goals and values.

Just two days ago--after the WSJ piece appeared--nine prominent medical societies issued a list of 45 medical tests or procedures the signatories felt should no longer be routinely given to patients. As Drs. Hartzband and Groopman point out, medical experts can't apply these rules without addressing the particular patient in front of them.

And what happens when the entire nation is required to finance a uniform package of care that is not suited to the needs of anyone in particular in that nation? Below are maps from the Centers for Disease Control that show the states with the most breast cancer on the left and the states with the most diabetes on the right. Do these states need the same list of approved tests and procedures?

Source: "Rise of the Medical Expertocracy," The Wall Street Journal Review, March 31, 2012.
Source: "Top 45 Ways to Cut Health Care Costs, According to Medical Groups," PBS Newshour, April 4, 2012.
Image courtesy of Centers for Disease Control. Used under fair use: public domain.

Steve O'Keefe is a freelance writer, author and book editor.