It is time to recognize a new fallacy, maybe not a logical fallacy up there with the ad hominem argument but surely, I believe, a political one. It might be termed “the real problem” fallacy. I first thought of it years ago when I told people I was interested in working on ethical and policy problems of medicine, even starting a research center on that topic. “But how can you justify focusing on that,” one person responded almost indignantly, “when the real problem is the proliferation of nuclear weapons?” Another said with identical language that “the real problem” is “the Israeli-Arab conflict.” Well, maybe so, but we just ignored them.
Then, many years later, closer to my own field, Christine Cassel wrote in her 2005 book, Medicare Matters, that “rationing appears unjustifiable when there are abundant opportunities to economize by improving efficiency and effectiveness in the health care system.” Just this year, Judith Feder, a professor at the Georgetown Public Policy Institute, said that it was wrong to focus on entitlement reform when “the problem is overall health care spending.” And so on: the real problem, a chorus of discordant cost control voices cry out, with Medicare is fee-for-service medicine, or background costs, or great regional variations in cost, or commercialized American medicine; or excessive use of technology.
Actually, one of them may indeed be the real problem (and my vote would go to the underlying costs of the system), but then why do I call it a fallacy? Its implication is that we have to solve a long-term underlying problem before we take on another one here and now before our eyes. Medicare has a critical cost problem right in front of us. We cannot wait until the almost intractable 50-year-year-old problem of waste and inefficiency has been vanquished. And we can hardly put off entitlement reform until we have done away with “excessive overall spending,” which could take generation or more to achieve, if at all.
Our health care system can be likened to a large and ailing schooner at sea in a storm. The wooden hull is rotting, dangerously taking on water, the weight of which is making the sails ineffective. The sails, as it turns out, are in shreds and must be repaired if the ship is to make it to port where the hull can be repaired. But patching the hull requires that men who should be working on the sails must have the boat stopped so they can swim under the hull to do the necessary work. Meanwhile, it is rumored that the nearest port may not be able to fix hulls or provide new sails – but that a much farther port, dangerously far, is well– equipped to do so. The consensus of the crew is that the real problem is the company that made such a boat, with a poor hull and bad sails; it should be sued.
The captain responds that the crew may well be right, but that is beside the point: the boat is sinking. Medicare is no less sinking. Whatever the underlying real problems, its reform must be begin at once, and by the most direct means possible (no falling back on bending the curve): cutting benefits and raising taxes.
Daniel Callahan, co-editor of the Health Care Cost Monitor, is the author most recently of Taming the Beloved Beast: How Medical Technology Costs are Destroying Our Health Care System.