On February 7, 2017, CNN hosted an interesting debate between Bernie Sanders, Independent senator of Vermont, and Ted Cruz, Republican senator from Texas, regarding the future of the Affordable Care Act.1
While the two did not break any ground as far as healing the rift over health care, they did address certain arguments that have classically defined the Republican and, to some extent, the Democratic positions.
In doing so, they showed clearly why the two parties are having such a hard time moving toward compromise. Nonetheless, the debate was most notable for several arguments proposed by Senator Cruz which, on the surface, appeared to be legitimate rebuttals to Senator Sanders, but with some minimal inspection turn out to be fallacious.
Senator Cruz drew numerous false conclusions based on misinterpreted facts — a tactic that is rampant in Washington among Republicans and Democrats alike. For example, at one point during the debate, Senator Cruz argued that countries with a national health-care system perform less imaging studies than we do in the US. He went so far as to argue that the reason Americans pay more for their health care is because “the United States, population controlled, delivers 3 times as many mammograms as Europe, 2.5 times as many MRI scans, and 31% more C-sections.” This is in fact a very true statement. However, the context in which he said it is extremely false.
It is true that part of the reason Americans pay more for their health care is because physicians order more “stuff.” However, what Senator Cruz implied is that more tests and more procedures must mean better outcomes, and thus better health care. This is just not the case. Over-utilization is a serious problem in the US, particularly when it does not result in better outcomes. Repeat and inappropriate imaging or procedures raise both health-care costs and risk for false positive results — which lead to further downstream testing or procedures, unnecessary patient anxiety, and increased lifetime risk for other diseases due to the additive effects of radiation exposure. Such practices clearly do not improve health care. In fact, they can lead to unfavorable consequences for patients.
Some might try to argue anecdotally that they caught an early lung cancer or breast cancer with what would today be considered inappropriate screening. But it has yet to be shown that such early detection results in improved morbidity or mortality. What has been shown in many cases is that globally screening a population that has a low incidence of disease with ionizing radiation actually increases the incidence of other diseases — and, in some cases, the very disease the screening was intended to detect.
In the last several years, there have been great efforts made by every specialty and subspecialty governing body to reduce the number of unnecessary tests performed on patients. Take, for example, the numerous documents, including white papers, consensus documents, and appropriate-use criteria, that have been published just in the field of cardiology to guide clinicians toward appropriate use of nuclear SPECT, PET, cardiac CT, echocardiography, nuclear stress testing, cardiac MRI, cardiac catheterization and other imaging modalities. The American College of Radiology and the Radiological Society of North America have formed a joint task force with a campaign, called Image Wisely: Radiation Safety in Adult Medical Imaging, specifically aimed at reducing exposure to ionizing radiation from medical imaging.2
The irony of Senator Cruz’s argument is that it supports the use of a national health-care system. In such a system, utilization can be better monitored, practice patterns can be better discerned, and feedback can more easily be disseminated to physicians — not through restrictions, as usually feared by the right, but by something as simple as offering more accurate feedback about their practice patterns to physicians.