Tom Daschle, President-elect Barack Obama's pick for secretary
of health and human services, has recently advocated the creation
of an independent "Federal Health Board." This board would bypass
Congress and make key health care decisions, such as determining
the cost-effectiveness of treatments and choosing which services
public insurance programs would cover. He has also suggested
expanding such a board's powers to private health plans.
Great Britain has a similar institution, the National Institute
for Health and Clinical Excellence (known by its acronym, "NICE").
Britain's experience with NICE offers insight into how such an
institution operates in practice.
The Federal Health Board
Daschle's health board would be modeled on the Federal Reserve
and would be similarly insulated from the political process.
Neither Congress nor the White House would have to approve the
health board decisions; a group of President-appointed "experts"
would run it.
Congress would commission the health board to conduct research
determining which drugs and procedures were "cost-effective" and
which were not. Based on its findings, the health board would issue
recommendations about which treatments should be used and how new
technologies should be deployed.
In Daschle's words, the health board "would have teeth." All
federal health programs would have to abide by the health board's
"recommendations," and the health board would determine which
treatments government insurance programs covered.
The health board would also regulate private insurance plans
operating in a new national health insurance exchange. Daschle
anticipates a spillover effect whereby private plans would adopt
coverage standards similar to those the health board would set for
public plans. Moreover, Daschle suggests that Congress could make
the employer tax exclusion for health insurance contingent on
private insurers' compliance with the health board's
British Patient Experiences
In Great Britain, NICE has broadly the same responsibilities
that would be delegated to the U.S. health board. In fact, Daschle
has cited scholars touting the use of NICE as a model.
NICE sets a threshold for cost-effectiveness that it applies
uniformly: It has decided that Britain should spend the same amount
saving or improving the life of a 75-year-old smoker as it would a
five-year-old. If a treatment is found to cost more than
about $30,000-$45,000 per "quality-adjusted life-year," it is
rarely covered. This approach has led to the denial of
- NICE restricted access to two drugs for Age-Related Macular
Degeneration, Britain's leading cause of blindness. The first drug,
Macugen, was completely blocked, while the second, Lucentis, was
limited to the approximately one in five disease sufferers who have
a specific type of the disorder. Even then, Lucentis was
restricted to patients with that type of the disorder in both
eyes--and could only be used in the less-diseased eye. In the words
of Tom Bremridge, chief executive of the Macular Disease Society,
"allowing one eye to go blind before treating the second eye is
cruel and totally unacceptable." Winfried Amoaku of the Royal
College of Ophthalmologists explained, "There are differences in
action between these two drugs, which may be important in
individual cases, and so we do not wish to be limited in our
treatment options in this way."
- NICE limited several Alzheimer's drugs to use in patients whose
disease had advanced from early to middle-stage. Even though
doctors argued that starting treatment at the onset of dementia
would be most effective in slowing the progression of the
disease, NICE decided that patients would have to
wait until they became sick enough for the treatments to meet the
cost-effectiveness threshold. A charity has taken legal action,
accusing NICE of "ignoring totally the proven benefits of the drugs
for careers of those with mild symptoms, and grossly
underestimating the savings they bring to the state by enabling
suffers to remain in their own homes longer. [The charity] accused
NICE of implying careers are far better off when the condition of
their sick relative deteriorates so much that they are forced to
move into a residential home."
- NICE blocked access to Glivec, a leukemia treatment. Ann
Tittley, a 55-year-old patient, was being treated for breast cancer
when she was diagnosed with leukemia. After realizing she would be
denied access to Glivec even though her physician had recommended
she start it immediately, Ms. Tittley wrote a letter to then-Prime
Minister Tony Blair. "Glivec was my lifeline, at least it would
give me a chance of beating this disease," wrote Ms. Tittley. "Life
is precious.... I appreciate that cost is important, but to deny
patients this potentially life-saving treatment on this basis is
totally unforgivable and criminal."
Health Care by Committee
In creating a Federal Health Board, Americans would trust that
remote, unelected bureaucrats isolated from public influence could
make health care decisions that would be right for every citizen.
The British experience with such policy should give lawmakers
pause. As Anthony Young, president of the British Association of
Endocrine Surgeons, has said, "There can be no guidelines that are
always right, always achievable, and always appropriate. Those of
NICE are no exception."
Jeet Guram is completing his academic
studies in biology and economics at the University of South
Carolina, and Robert E.
Moffit, Ph.D., is Director of the Center for Health Policy
Studies at The Heritage Foundation.
Daschle, Scott S. Greenberger, and Jeanne M. Lambrew, Critical:
What We Can Do About The Health-Care Crisis (New York, N.Y.:
Thomas Dunne Books, 2008), especially part 4 (pp. 139-180).Versions
of a health board have been included in other prominent proposals.
See U.S. Senator Max Baucus, "Call to Action: Health Care Reform
2009," November 12, 2008, at http://finance.senate.gov
/healthreform2009/finalwhitepaper.pdf (December 3, 2008),
especially chapter 2 (pp. 13-35); Ezekiel Emanuel and Victor Fuchs,
"A Comprehensive Cure: Universal Health Care Vouchers," Brookings
Institution, July 2007, at http://www.brookings.edu/~/media/Files/rc/pa
3, 2008), especially chapter 2 (pp. 7-11).
additional discussion of the health board, see Stuart Butler, "Life
or Death? Ask U.S. Health Board," The Washington Times,
September 18, 2008, at http://www.washingtontimes.com/news/
2008). For discussion of the implications of comparative
effectiveness analysis for drug development, see Anupam B. Jena and
Tomas J. Philipson, Innovation and Technology Adoption in Health
Care Markets (Washington, D.C.: AEI Press, 2008), at /static/reportimages/A6213E8DC25B2961D0A428436B27F3E0.pdf(December
Daschle, Greenberger and Lambrew,
Critical, p. 173.
study in the New England Journal of Medicine found that
Lucentis slowed vision loss in 90 percent of tested patients and
improved vision in about a third, "Anger over Blindness Drugs
Ruling," BBC, June 13, 2007, at http://news.bbc.co.uk/2/hi/health/6749351.stm(December