HEALTH CARE MAY 19, 2011
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In 1959, the great biologist René Dubos wrote a book called Mirage of Health, in which he pointed out that “complete and lasting freedom from disease is but a dream remembered from imaginings of a Garden of Eden.” But, in the intervening decades, his admonition has largely been ignored by both doctors and society as a whole. For nearly a century, but especially since the end of World War II, the medical profession has been waging an unrelenting war against disease—most notably cancer, heart disease, and stroke. The ongoing campaign has led to a steady and rarely questioned increase in the disease-research budget of the National Institutes of Health (NIH). It has also led to a sea change in the way Americans think about medicine in their own lives: We now view all diseases as things to be conquered. Underlying these changes have been several assumptions: that medical advances are essentially unlimited; that none of the major lethal diseases is in theory incurable; and that progress is economically affordable if well managed.
But what if all this turns out not to be true? What if there are no imminent, much less foreseeable cures to some of the most common and most lethal diseases? What if, in individual cases, not all diseases should be fought? What if we are refusing to confront the painful likelihood that our biological nature is not nearly as resilient or open to endless improvement as we have long believed?
Let us begin by pointing to some unpleasant realities, starting with infectious disease. Forty years ago, it was commonly assumed that infectious disease had all but been conquered, with the eradication of smallpox taken as the great example of that victory. That assumption has been proved false—by the advent, for example, of HIV as well as a dangerous increase in antibiotic-resistant microbes. Based on what we now know of viral disease and microbial genetics, it is reasonable to assume that infectious disease will never be eliminated but only, at best, become less prevalent.
Then there are chronic diseases, now the scourge of industrialized nations. If the hope for eradication of infectious disease was misplaced, the hopes surrounding cures for chronic diseases are no less intoxicated. Think of the “war on cancer,” declared by Richard Nixon in 1971. Mortality rates for the great majority of cancers have fallen slowly over the decades, but we remain far from a cure. No one of any scientific stature even predicts a cure for heart disease or stroke. As for Alzheimer’s, not long before President Obama recently approved a fresh effort to find better treatments, a special panel of the NIH determined that essentially little progress has been made in recent years toward finding ways to delay the onset of major symptoms. And no one talks seriously of a near-term cure.
One of the hardiest hopes in the chronic-disease wars has been that of a compression of morbidity—a long life with little illness followed by a brief period of disability and then a quick death. A concept first introduced by James Fries in 1980, it has had the special attraction of providing a persuasively utopian view of the future of medicine. And it has always been possible to identify very old people who seemed to have the good fortune of living such a life—a kind of end run on medicine—and then dying quickly. But a recent and very careful study by Eileen Crimmins and Hiram Beltran-Sanchez of the University of Southern California has determined that the idea has no empirical support. Most of us will contract one or more chronic diseases later in life and die from them, slowly. “Health,” Crimmins and Beltran-Sanchez write, “may not be improving with each generation” and “compression of morbidity may be as illusory as immortality. We do not appear to be moving to a world where we die without experiencing disease, functioning loss, and disability.”
Average life expectancy, moreover, steadily increasing for many decades, now shows signs of leveling off. S. Jay Olshansky, a leading figure in longevity studies, has for some years expressed skepticism about the prospect of an indefinite increase in life expectancy. He calls his position a “realist” one, particularly in contending that it will be difficult to get the average beyond 85. He also writes that it is “biased” to assume that “only positive influences on health and longevity will persist and accelerate.” That view, he notes, encompasses a belief that science will surely keep moving on a forward track—a projection that is not necessarily true. Simply look at the “breakthroughs” that have been predicted for such scientific sure things as stem-cell technology and medical genetics—but have yet to be realized. These breakthroughs may eventually happen, but they are chancy bets. We have arrived at a moment, in short, where we are making little headway in defeating various kinds of diseases. Instead, our main achievements today consist of devising ways to marginally extend the lives of the very sick.
There are many ways of responding to this generally pessimistic reading of medical innovation in recent years. The most common is simply to note all the progress that has been made: useful new drugs, helpful new devices and technologies, decreased disability, better ways of controlling pain, and so on. And it is certainly true that some aspects of medicine have made enormous strides over the past few decades. Some of these strides, in fact, have taken place in the very areas—such as cardiac and infectious diseases (for instance, treatment of HIV)—in which so much of the outlook remains otherwise unpromising. One of us was the beneficiary of a life-saving heart operation at age 78, of a kind that did not exist a decade ago (and both of us celebrated our eightieth birthdays this past year). Americans do live longer, by eight to nine years since 1960; a great range of treatments are available for our illnesses, mild or severe; our pain is better relieved; and our prospects for living from youth to old age have never been greater.
It might also be said that there is no reason to believe that cures for infectious and chronic diseases cannot eventually be found; it is just taking longer than expected and the necessary knowledge for breakthroughs seems to be slowly accumulating. Or it might be said that more people living longer, though sick, is a not inconsiderable triumph.
These advances, however, should be balanced against another factor: the insupportable, unsustainable economic cost of this sort of success. Twenty years from now, the maturation of the baby boom generation will be at flood tide. We will have gone from 40 million Americans over the age of 65 in 2009 to 70 million in 2030. This will put enormous pressure on the health care system, regardless of whether Obama’s reform efforts, or even Paul Ryan’s, prove successful. The chronic diseases of the elderly will be the front line. Because we cannot cure those diseases at present, nor reasonably hope for cures over the next few decades, the best we will be able to do in many cases, especially those of the elderly and frail, is extend people’s lives for a relatively short period of time—at considerable expense and often while causing serious suffering to the person in question.
Consider that a National Cancer Institute study projects a 39 percent increase in cancer costs between 2010 and 2020. That figure represents in great part our success in extending the lives of those already afflicted with the disease. Kidney dialysis also has become an economic quagmire. A 150 percent increase in the number of such patients is expected over the next decade. The cost of Alzheimer’s disease is projected to rise from $91 billion in 2005 to $189 billion in 2015 to $1 trillion in 2050 (twice the cost of Medicare expenditures for all diseases now).
In a 2006 article, Harvard economist David Cutler and colleagues wrote, “Analyses focused on spending and on the increase in life expectancy beginning at 65 years of age showed that the incremental cost of an additional year of life rose from $46,800 in the 1970s to $145,000 in the 1990s. ... If this trend continues in the elderly, the cost-effectiveness of medical care will continue to decrease at older ages.” Emory professor Kenneth Thorpe and colleagues, summing up some Medicare data, note that “more than half of beneficiaries are treated for five or more chronic conditions each year.” Among the elderly, the struggle against disease has begun to look like the trench warfare of World War I: little real progress in taking enemy territory but enormous economic and human cost in trying to do so.
In the war against disease, we have unwittingly created a kind of medicine that is barely affordable now and forbiddingly unaffordable in the long run. The Affordable Care Act might ease the burden, but it will not eliminate it. Ours is now a medicine that may doom most of us to an old age that will end badly: with our declining bodies falling apart as they always have but devilishly—and expensively—stretching out the suffering and decay. Can we conceptualize something better? Can we imagine a medicine that is more affordable—that brings our health care system’s current cost escalation, now in the range of 6 percent to 7 percent per year, down to 3 percent, which would place it in line with the annual rise in GDP? Can we imagine a system that is less ambitious but also more humane—that better handles the inevitable downward spiral of old age and helps us through a somewhat more limited life span as workers, citizens, and parents?
The answer to these questions is yes. But it will require—to use a religious term in a secular way—something like a conversion experience on the part of physicians, researchers, industry, and our nation as a whole.
Vannevar Bush, ascientific advisor to President Franklin D. Roosevelt, famously said that science is an “endless frontier.” He was right then and that is still true now. But scientific progress to extend that frontier is not an endlessly affordable venture. Health care, like the exploration of outer space, will always be open to progress, but we understand that putting humans on Mars is not at present economically sensible. We have settled for a space station and the Hubble telescope. We must now comparably scale down our ambitions for medicine, setting new priorities in light of the obstacles we have encountered.
We need, first of all, to change our approach to research. A key ingredient of the economic engine of medical progress has been the endless issuing of promissory notes by scientists and the medical industry, which are then amplified by the media. The human genome project, stem-cell research, highly touted “breakthroughs”—all have raised hopes that we are on the verge of saving hundreds of millions of lives. But these promises have not materialized. A more realistic rhetoric is necessary, one that places a heavier emphasis on caring for the sick, not curing them.
The traditional open-ended model of medical research, with the war against death as the highest priority, should give way to a new goal: aiming to bring everyone’s life expectancy up to an average age of 80 years (already being approached), reducing early death, and shifting the emphasis in the direction of improving the quality of life of those in every age group. The highest priority should be given to children, the next-highest to those in their adult years (the age group responsible for managing society), and the lowest to those over 80.
In light of the fact that we are not curing most diseases, we need to change our priorities for the elderly. Death is not the only bad thing that can happen to an elderly person. An old age marked by disability, economic insecurity, and social isolation are also great evils. Instead of a medical culture of cure for the elderly we need a culture of care, notably a stronger Social Security program and a Medicare program much more heavily weighted toward primary care. Less money, that is, for late-life technological interventions and more for preventive measures and independent living. Some people may die earlier than now, but they will die better deaths.
Bringing about these changes would require shifts in the medical profession. Imagine a health care pyramid. At the lowest and broadest level is public health (health promotion and disease prevention). The next level is primary medicine and emergency care. The level above that consists of short-term hospital care for acute illness. And the top, narrowest level is high-technology care for the chronically ill. It is essential that we find ways to push down the ever-expanding kind of care at the highest level to lower levels, and particularly to the public-health and primary-care levels. The standards for access to care at the highest levels should be strict, marked by a decent chance of good outcomes at a reasonable cost.
Along these lines, one obvious step is to encourage more medical students to become primary-care physicians rather than specialists. Though there is nothing new or radical in such a proposal, it will not be easy to implement. Medical education must be better subsidized to reduce the debt of young doctors, which discourages many from entering family practice and tempts them toward ever-narrowing and more lucrative specialties.
Yet the most difficult shift will have to take place not among doctors, but among the public as a whole. The institution of medicine is enormously popular with the public. None of us likes being sick or threatened with death. Modern technology has brought us many benefits that enhance the prestige and social power of medicine. But the public must be persuaded to lower its expectations. We must have a society-wide dialogue on what a new model of medicine will look like: a model that will be moderate in its research aspirations, and dominated by primary care and neighborhood clinics staffed mainly by family physicians, paramedics and nurses for routine health needs, and organized teams for acute care. If this society-wide dialogue is to be successful, doctors will have to call repeated attention to the economic and social realities of the endless war on disease. They will have to remind the public that this war cannot be won—or can achieve small, incremental victories only—and if we are not careful, we can harm ourselves trying.
Finally, we need a health care system that is far more radically reformed than the system envisioned by the Affordable Care Act (ACA). Should the ACA be successful down to the last detail, it is still unlikely to succeed in bringing the annual rise in health care costs down to the annual GDP increase. In their 2011 yearly report, the Medicare program trustees project insolvency by 2024. The only reliable way of controlling costs has been the method used by most other developed countries: a centrally directed and budgeted system, oversight in the use of new and old technologies, and price controls. Medicine cannot continue trying to serve two masters, that of providing affordable health care and turning a handsome profit for its middlemen and providers.
Even so, those countries with less costly but more effective health care systems are in trouble as well—not as much as we are, but enough to inspire constant reforms. Every health care system has to cope with aging populations, new technologies, and high patient expectations. However a health care system is organized, the open-ended idea of medical progress is the deepest driver of health care costs. It dooms us to live too much of our later years in poor and declining health, and to die inch by inch from failure of one organ after another. Is it really a medical benefit, for ourselves or our families, to be doomed by frailty to a life that makes even walking a hazard? Or to spend our last years in and out of doctors’ offices and ICUs? Those results are what progress has given us—a seeming benefit that has become a serious economic and personal burden.
“All politics,” the late and wise Tip O’Neill once said, “is local.” It can no less be said that “all medicine is personal.” Our own experience in trying to talk about the kind of wholesale reforms we think necessary for medicine’s future is that people are far more concerned about what it will mean for themselves and their families than for something as general and abstract as the health care system. Their heads tell them that rationing and limits will probably be necessary, but they reject these ideas if it means that a loved one might not have what is needed to be kept alive, even if in a bad or terminal state. Unhappily, however, some rationing and limit-setting will be necessary. There is no way the Medicare program can survive unless it both sharply cuts benefits and raises taxes. Certain benefits can be cut directly or indirectly—directly by reducing payments for treatments, or indirectly by increasing co-payments and deductibles to a painful level, sufficient to discourage people from insisting on them.
But our broader point is not really about policy changes such as rationing. It is, put simply, that substantial shifts will be needed in the way our culture thinks about death and aging. There is good evidence that if physicians talk candidly and with empathy to critically ill patients and their families, telling them what they are in for if they want a full-court press, minds can be changed. That, in turn, means that physicians themselves will have to acknowledge their limits, explore their own motivations, and be willing to face patients with bad news as a way of avoiding even worse treatment outcomes. The ethic of medicine has long been to inspire unbounded hope in the sick patient and the same kind of hope in medical research. Sobriety and prudence must now take their place.
The problems we are describing are, of course, hardly the only flaws within the U.S. medical system. Among the spheres of concern most commonly cited for major criticism are: the perception of significant deterioration in the doctor-patient relationship; the state of care at the end of life; maldistribution of health care availability among geographic locations; malpractice and tort law; physician entrepreneurship; emphasis on profit motive by the insurance and pharmaceutical industries; duplication of resources among competing health facilities; multiple tiers of access and care, largely determined by income; wasting of money, resources, and personnel within the system; and costly overspecialization.
Sometimes—at all times, actually—the problems seem overwhelming. Not only does the complexity of the issues make them appear insoluble, but so does the way in which each seems to intertwine with all the others, inevitably to exacerbate the whole. The entire web of interconnected, complicating factors has long since reached the bewildering point where no issue can be addressed, or so much as approached, in isolation. The complexities are enough to make every stakeholder in American medicine—namely all of us—throw up our hands in desperation.
But there is, in fact, a solution: a top-down, bottom-up study of the entire U.S. health system, with a view toward taking it apart and reconstructing it in a manner adapted to our nation’s needs—a multiyear, multidisciplinary project whose aim would be to change the very culture of American medicine. The inadequate, inequitable, and financially insupportable system that has been jerry-built and constantly band-aided during recent decades will no longer do. Nor will incremental policy reforms, no matter how well-intentioned.
There is a historical precedent for such a project. At the turn of the twentieth century, U.S. medical education was a disgrace, and care of the sick, except in a certain few facilities, was almost as bad. Something had to be done. In 1908, the newly founded Carnegie Foundation for the Advancement of Teaching stepped in, hiring a 42-year-old educator named Abraham Flexner to embark on a study of medical education in North America. His report, published two years later, became a clarion call for drastic change. Subsequently, armed with a total of $600 million provided by the Carnegie and Rockefeller philanthropies and other contributors, Flexner visited 35 schools in the United States and Canada, and provided the financial wherewithal for the changes so desperately needed. The result of this remarkable effort was that, within ten years, U.S. medical schools became the prototype upon which all others tried to fashion themselves; our nation’s medicine, like the vastly improved institutions that gave it new life, became the gold standard for the world.
We can do this kind of thing again. It will take political will; unyielding leadership; vast amounts of money, both from government and private philanthropy; and extreme patience. Above all, it will take the confidence of the American people that a more humane, more affordable kind of medicine is possible.
Daniel Callahan is president emeritus of the Hastings Center and the author of Taming the Beloved Beast: How Medical Technology Costs Are Destroying Our Health Care System. Sherwin B. Nuland is a fellow of the Hastings Center and a retired clinical professor of surgery at Yale University. He is the author of How We Die and The Art of Aging. This article originally ran in the June 9, 2011, issue of the magazine.
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47 comments
"The only reliable way of controlling costs... a centrally directed and budgeted system, oversight in the use of new and old technologies, and price controls." The Left is amusing. If private insurance tries to restrict treatment options to what can be afforded, the government brings on laws mandating more comprehensive coverage. When such coverage becomes unaffordable, the government steps in to mandate what it wouldn't let private insurers do--restrict coverage. For private insurance to work, tiers of coverage would be needed to accommodate various incomes. It's not trivial to implement, but it is possible--not that the Left would entertain such ideas!
- karlwk
May 22, 2011 at 9:13pm
This is an excellent article. As the saying might go, every silver lining has a razor in it. We have made immense progress in overcoming many of the hazards and illnesses that frequently killed people before they completed a "natural" life span. My father died of his second heart attack at the age of 48. I am surprised to find myself alive (and fairly healthy) at the age of 67. My mother live to her 30s, but was trapped for many years in Alzheimer's Disease. The thought of succumbing to that fate creeps me out quite a bit. Is it because I take omega-e rich fish oil? Is it because I exercise fairly regularly and keep my weight under control [Etc., etc.] Unfortunately, as this article touches upon, these solutions create serious problems and dilemmas for our society. I would prefer to stay alive as long as I can while maintaining reasonable physical and mental vigor. I would prefer to die quietly in my sleep then slowly with cancer eating my brain (as an acquaintance of mine just did) or of some other painful and excruciatingly drawn out process, but usually we just get the "luck of the draw" in these matters. These issues and dilemmas are going to become more and more expensive and difficult for to deal with individually and collectively. Very good (if depressing) issue of New Republic. I am a satisfied morbid customer.
- skahn
May 29, 2011 at 12:45am
The problem, karl, is that insurance companies are hopelessly, ethically conflicted. It is one thing for the society as a whole to decide not to pay for a particular type of care. It is rather another when an insurance company that earns $1 for every $1 of care it denies to make that decision. We rightly don't want to allow insurance companies to do that, but we have to do it as a society.
- roidubouloi
June 1, 2011 at 12:33am
roi, your philosophy has been tried and found wanting. It has led to the violent deaths of hundreds of millions of innocent people. Here's your homework for the day: Compare North and South Korea. The idea that "society", i.e. government, should make all the decisions that in a free country are left to the individual and the family is known as totalitarianism. It has caused human misery beyond measure, beyond human comprehension. Even in its milder form, known as socialism, it has led western Europe into moral, economic and social decline. Unless America wakes up we will go down the same rat hole.
- bulbman1066
June 1, 2011 at 4:19am
Interesting, as the philosophy of social democracy prevails throughout most of Europe and Japan and seems to work for them. In fact, I have yet to meet someone from any of the other countries in the OECD that has universal health care (which is almost all of them) who complained that a North Korea-like government was a totalitarian threat to freedom that had to be stopped by all means. This "road to serfdom" meme is profoundly stupid. Does the fact that we live in a society where big business has enough power to bankroll political campaigns mean we are on "the road to fascism"? Possibly. But if you see everything through the prism of maximalist ends, you shouldn't be taken seriously.
- chaitless
June 1, 2011 at 5:56am
I've made the same argument many times, just less comprehensively. Of course, it won't happen. Why? Because Americans simultaneously believe every older American is entitled to comprehensive health care and every American who can afford it is entitled to whatever health care he or she can afford. Sure, that dichotomy exists today, but the radical shift in emphasis described by the authors, away from care for older Americans to younger Americans, would result in two very different, and apparent, health care systems, one for wealthy Americans and one for everybody else. That will never happen as long as public financing for elder health care is the primary means of funding such care. On the other hand, if the Ryan plan were adopted, it would happen as a matter of economics. At least for a while. Until public reaction forced Congress to undo the Ryan plan, the same public reaction that lead to the adoption of Medicare in the first place: the public's unwillingness to accept large scale poverty among the elderly. It's for that reason that I describe the Ryan plan as one of deferral of the cost (i.e., taxes) of funding comprehensive health care for the elderly (including, unfortunately, the extraordinay life prolonging care at the end of life). The essential ingredient to a shift in emphasis in care as described by the authors is a radical shift in attitudes about death and dying. One would assume that in this "Christian nation" such a shift in attitudes wouldn't be that difficult (for believing Christians, death is our reward), but Americans are no more serious about their religious beliefs than they are about the principles of democracy. I agree with everything the authors say. But as I said already, it won't happen.
- rayward
June 1, 2011 at 7:53am
Hear, hear. But I fear that rayward may be right about the poor likelihood of such a revolution's coming to pass. I, an infectious diseases physician, have made similar arguments on these boards suggesting that we are blowing our bankroll in a frantic effort to buy old people a few more years of often quite poor-quality life, and I have generally been attacked as heartless, "pernicious," a bad doctor, a doctor with a God complex, and possibly a liar who isn't a doctor at all. One thing Callahan and Nuland highlight that I've not heard too many others mention but that is all too apparent to me in my own study and medical practice: the fact that we are running up against (have already run up against?) a technological wall when it comes to further advances in medical treatment. Take the example of the treatment of atherosclerotic vascular disease--the single biggest killer of adults in the developed world. Huge advances were made in the '80s with the introduction of cholesterol lowering drugs, the invention of angioplasty, the development of thrombolytic therapy for acute myocardial infarction (and later stroke), and the recognition of the cardiovascular benefits of drugs like aspirin, beta-blockers, and ACE-inhibitors. The advances lead to significant improvements in survival and tended to benefit relatively young patients, men in their 50s and 60s, women in their 60s and 70s. The '90s saw continued improvements in and refinements of the new treatments introduced the decade prior as well as the introduction of a couple of new classes of drugs which produced real but somewhat more modest increases in survival as well as the hugely expensive automated, implanted defibrillators which work well but about a third of the time get placed in patients who don't meet criteria for likely benefit, thus decreasing the cost-effectiveness even further. The '00s saw virtually no additional improvement. In fact, the biggest research finding of the past decade in cardiovascular medicine was that angioplasty doesn't actually make people live longer--something we pretty much already knew but weren't quite ready to accept--and what's more, that the drug-eluting angioplasty stents which were touted as the whiz-bang next generation of life-saving technology were actually worse, in many cases, than the old fashioned bare-metal stents in use for more than twenty years. With the caveat that I am not a cardiologist and spend more of my time reading about microbes than atherosclerotic plaques, I feel reasonably confident in saying that there are no new game-changing technologies on the horizon in cardiovascular medicine. And the scarcer beneficial discoveries become, the more money we have to spend for each one that we do stumble across.
- AaronW
June 1, 2011 at 10:22am
Bulbman, you know South Korea has a universal healthcare system right?
- Pnaut
June 1, 2011 at 12:00pm
Yes, South Korea has a universal healthcare system, but it works much better than say the Canadian system (as a Canadian who has lived in Korea notes) because the government covers only about 55% of the total cost of medicine. My point was not that government controlled medicine automatically leads to totalitarianism. It doesn't. My point is that ignorance of the way markets work, as shown by roi's belief that government mandate is ipso facto morally superior to individual choice, does lead to the loss of liberty. The example of North Korea (or any Communist country) shows what happens when roi's philosophy is taken to its logical conclusion. The Europeans and the British are moving away from socialism. They have discovered it to the be road to economic ruin. Let's benefit from the mistakes of others rather than imitating them.
- bulbman1066
June 1, 2011 at 1:11pm
In response to "bulbman," your light bulb appears to have gone out. You're repeating the same, ridiculously uninformed and distorted pablum, rooted in myth, spewed by the usual suspects. As far as the article, and several of the responses, there is absolutely no mention other than one short sentence, about PREVENTION! How did these elderly folks get to where they are now? Could it be the lousy, commercialized, packaged high-fat , -sugar and -sodium American diets, or the very prevalent obesity, no exercise, etc.? Without aggressively changing these foundational health problems of our society (and CONservatives, get off the nonsense about liberty, etc., which is probably where you're headed -- what good is liberty without the self-respect to make healthy choices! You merely become a burden to the society you don't want to help pay for. No, a civilized society will care for anyone in need...) just how healthy will the young, which you're so keen on sustaining, be as they age? I've certainly benefitted from modern medicine's advances, but I've benefitted MORE from a healthy, low-fat Mediterranean-type diet, getting back to my college weight (I'm 63) and making sure I get off my bottom for daily walking (at the very least). The emphasis on technology and advances in medicine somehow patching up a life poorly lived is sad, to say the least. If that's the best we can do, of course we're doomed to expensive and painful failure.
- sustaingai
June 1, 2011 at 2:19pm
good lord Bulbman, what a big strawman you built there. So South Korea has a very successful government run healthcare program which shows that somehow government run healthcare programs are bad because they are (booga booga) socialistic. Yes, let privatize the military too. See I could do reductio ad absurdum just as well as you with roi. Try to focus a little, mm kk? The US created a health care progam that only took in the oldest and most likely to become seriously sick group of people and financed it with taxes leaving young, healthy people to fend for themselves forking over money to private insurance companies who take a huge chunk of the premiums for overhead and profits. Now imagine you funnel all of those premiums into that government run program via taxes. Suddenly there is no more Medicare crisis. In fact, our health care costs would drop quickly overnight and perhaps we can be like the other OECD nations and spend far less of our GDP on health care. But NOOOOO, dat am bad because (booga booga) capiaoalismum am always gooder, right?
- blackton
June 1, 2011 at 2:29pm
Managing chronic illness (I include old age as a chronic illness) is the future of health care, not curing disease. As others point out, recent advancements in medicine mostly add to the life expectancy of those with chronic illness. Cancer, heart disease, diabetes, even old age, they are no longer death sentences. Unfortunately, the overall cost of health care goes up exponentially. We like to say that children are our future. Yet we devote far more resources to those at the end of life. More open and realistic discussion among physicians about choices at the end of life would go a long way to changing attitudes. Atul Gawande is very good, as are these two authors. Cohn would be very good at developing a regular column in TNR on the subject.
- rayward
June 1, 2011 at 2:49pm
Government doesn't provide most goods and services, the private sector does, and there's a reason for this. Government is a high-cost, inefficient provider. That's why Cuba, yes Cuba, is on the verge of privatizing industry and agriculture. That's why China, India and the countries of the former Soviet Union moved in the same direction. There is this strange superstition that alone among all enterprises medicine is best when run by government. It is a superstition which cannot stand up to the light of close analysis. Nobel Prize winning economist Kenneth Arrow showed that government social programs achieve the most benefit and the least harm when they interfere least with the market economy. For example, to make certain that low-income people have enough to eat we have Food Stamps, coupons that can be used to pay for groceries. The government hasn't taken over the farms. That's fortunate, because where that approach has been tried the results have ranged from food being of poor quality and in short supply to mass famine.
- bulbman1066
June 1, 2011 at 4:04pm
AaronW Good points in your post, but it isn't just a technological wall. some of it is self inflicted. Public funding for basic research on a whole bunch of medical fields has been scaled back over the past few decades. Big Pharma has not been picking up the slack (blue sky research is too risky for anybody who has to justify funding one quarter at a time to Wall St types...). they'll put their money where they can build on something that's already there, even if it means making claims that they're only a few percent better than the competition. In short, we've been eating our seed corn, with the private sector reaping the benefits of publicly funded research that was financed years ago. I'm not a life sciences professional, but I'm married to one, and I wouldn't be so gloomy about the potential for further big, big advances in cardiology, or in medicine as a whole. Who knows, somebody might come up with a chemical treatment that dissolves plaque slowly, so no pieces break off. Maybe there's a nanotech agent that can bind to cholesterol and prevent it from attaching in the first place. That's not on the horizon now, but that's because we are no longer standing on the shoulders of giants. We only think we are, because we're surrounded by dwarfs.
- gwcross
June 1, 2011 at 4:06pm
sustaingai makes the important point that people need to eat right and exercise. But surely the most effective way to bring that about is to let people shop for their medical insurance so that they can buy policies that give a discount for people who live a healthful lifestyle. Incentives work, and for there to be incentives we need for people to pay to the greatest extent possible out of their own pocket for health care. Subsidies that insulate people from the consequences of their behavior are the root of all evil. We saw that in the real estate meltdown. Fannie Mae and Freddie Mac and private banks and brokerage houses were encouraged by the federal government to lend money to unqualified borrowers, with the taxpayer assuming the risk. The result should have been predicted. Another example is government flood insurance, which encourages people to build in flood plains.
- bulbman1066
June 1, 2011 at 4:24pm
sustaingal, the reason Callahan and Nuland make no mention of PREVENTION is because PREVENTION has no role in the reduction of the total amount of wealth our society expends on medical care. The only way that prevention could result in a decline in expenditures is if it led to a "compression of morbidity", i.e. if it increased the proportion of the population who avoided chronic disease altogether, made it to old age in good health and then died after a brief illness. While these author's make no specific mention of preventative medicine, they make a good case that compression of morbidity has not and cannot be achieved by any
- AaronW
June 1, 2011 at 4:38pm
...has not and cannot be achieved by any means.
- AaronW
June 1, 2011 at 4:39pm
The authors make the best case I have yet heard for death panels.
- JohnEMack
June 1, 2011 at 5:03pm
Bulbman, what about an insurance company that will pocket very dollar of care it denies decidng to deny you that care strikes you as "individual choice?" You really don't know the first little thing about economics, do you? Someone has to make a decision about what to spend and what not to spend. If we leave that entirely to individuals, or even mostly to individuals, to pay out of their own pockets, then health care will be rationed based on the ability to pay. That is not individual choice except for those who have the means. Everyone else who does not have the means is then expected to get sick and die. That is savagery, the barbarism that your disgusting political philosophy represents. It is not the road to freedom. It is not the road to economic growth. It is the road to hell, rightly rejected by every modern, civilized, industrial society whether capitalist or socialist. If decisions about what is worth spending money on are not to be made by individuals based on willingness and ability to pay, there are exactly three other choices that I know of, unless you can conjure another one: The decision can be made by private insurance companies, who make money by denying care, or it can be made by government based on protocols that are applied to everyone in the same circumstances, one method of ensuring decency and fairness or we can pay whatever the medical profession asks for whatever service it wants to provide. Any person with so much of an ounce of common sense would understand that having the insurance company that profits directly from your distress make that call would be disastrous. That actually leaves two other alternatives, the government decides what to pay and what to pay for based on the adoption of universal protocols, or we simply pay whatever the medical profession asks for whatever it wants to do. Right now, we are primarily in the position of paying whatever the medical profession asks for whatever it wants to do. As there is no "demand side" of the market to control costs and consumption, they are out of control and rapidly becoming unaffordable for the society. So, here are your choices (unless you can come up with a plausible case for another). Tell us which you prefer so we will understand what sort of human being you are: 1. Care is allocated based on individual ability to pay, 2. Care is allocated by insurance companies based on their profit targets, 3. Care is allocated by government based on universal protocols and prices set by government, 4. We pay whatever the medical profession asks for whatever service it wants to provide, efficacious or not.
- roidubouloi
June 1, 2011 at 8:05pm
We spend 17.5% of GDP on medical care, and rising. In France, the spend 11% of a smaller per capita GDP, have universal coverage, and medical outcomes as good as ours. Proving, bulbman, that you have no idea what you are talking about and no interest in facts. Like the couple of other libertarian absolutists around here, you simply keep repeating your little Randian talking points without any reference to reality whatsoever. Pure religious belief on a par with the world being carried on the back of a great turtle. Hence, for example, your little farce about North and South Korea, failing to note that South Korea has exactly the medical system you deplore.
- roidubouloi
June 1, 2011 at 8:13pm
Roi, I'll give you 8.7% of GDP federal expenditures to cover all US HC, which equals French public spending. Leave me a private market for anything above that. Fair deal? - One of your resident libertarians.
- ds111
June 1, 2011 at 10:18pm
Give me 11%, like the French, single-payer (with control of consumption and price), universal coverage, and its a deal. That is, give me the French system, and you can buy whatever private health care that you want (and fly in your private 727 do get it). You can even have private health insurance to pay for it. But, if you buy privately, you don't get the subsidy. You are on your own. Otherwise, it really is a two-tier system. Just the way public school taxes go to pay for public schools, not as a contribution toward the cost of private schools from which most are excluded.
- roidubouloi
June 1, 2011 at 10:43pm
Another thing. Insurance companies make very little on health insurance, your diatribes notwithstanding. I don't like the model because it is hard to evaluate actuarially, one of the reasons ins cos spend so much on anti-fraud. They don't want to be the chumps. They have become conduits, which charge enough premium the next year to cover the previous years expenses plus a small profit. Hence, ever increasing premiums - making us the chumps. The model works much better with HSAs because it is true insurance, as a large deductible discourages fraud. Have your public option, but be responsible enough to cover everyone while limiting federal expenditures to something around the OECD public average. We will have a two-tier system, but everyone will have basic coverage.
- ds111
June 1, 2011 at 10:45pm
French public pays 8.7%, the rest is private add ons. That's would be a deal, but would have to cover everybody. But of course I'm a believer in vouchers, given my view of the public schools generally - though my kids are all in public schools, as was I, good enough, not great, but I'm a fan. Allow a fair weighted voucher option, even if only for an HSA and a bit of "premium support," and I'd go along. Everyone should have coverage. Define the public cost, and it's just a question of how.
- ds111
June 1, 2011 at 11:03pm
French public pays 8.7%, the rest is private add ons. That would be the deal, but would have to cover everybody. But of course I'm a believer in vouchers, given my view of the public schools broadly - though my kids are all in public schools, as was I, good enough, not great, but I'm a fan. Allow a fair weighted voucher option, even if only for an HSA and a bit of "premium support," and I'd go along. Everyone should have coverage. Define the public cost, and it's just a question of how.
- ds111
June 1, 2011 at 11:05pm
Easy peasy, ds111. We'll create a system of public, government-run hospitals and clinics whose medical staff work on salary, not fee-for-service modeled after public hospitals in places like Canada and Australia (where I work) or, if you like, modeled after the VA system. The only two criteria for admittance to one of these hospitals will be that A) you're sick and B) you have a social security number. Right there you'll eliminate the administrative overhead from private insurance that currently adds something like 10% to health care costs. The next thing we'll do is establish a national drug formulary modeled on the VA system's that will negotiate en-bloc purchasing from drug manufacturers and where practically equivalent drugs exist will only offer the choice whose manufacturer offers the cheapest price (Here's one way that a functioning market could actually operate to put the brakes on rising health care costs.) Will that limit individual choice? Sure, but really only the choice to be bamboozled by drug companies. (If you believe that the Nexium AztraZeneca pushes so relentlessly in direct-to-patient ads actually fixes your heartburn better than generic over-the-counter ompeprazole, you've drunk the Kool Aid.) Finally. we'll get explicit about the kinds of treatment we will and will not offer for particular groups of patients. We'll have a public debate about how much money is too much money to spend for each quality-adjusted life year saved. I don't know how much is too much--$50,000? $100,000? more?--but there has to be a number, a limit beyond which we cannot afford to spend, and once a number is agreed upon, applying those rules to generate protocols such as "no open heart surgery for anyone over 83" or "no dialysis for anyone over 70 who also has diabetes" become a fairly straightforward matter. And if you want to create a parallel private health system (such as we have here in Aus) where people with the money to spend can purchase supplemental private health insurance that will give them access to treatments denied under the public scheme, I don't have any major problem with that, though if the public system is properly designed such private moneys will most of the time amount to wasteful luxury spending.
- AaronW
June 1, 2011 at 11:13pm
Exactly AaronW! The way it must be if we are to cover everyone.
- ds111
June 1, 2011 at 11:30pm
roi writes: "Give me 11%, like the French, single-payer (with control of consumption and price), universal coverage, and its a deal. That is, give me the French system, and you can buy whatever private health care that you want (and fly in your private 727 do get it). You can even have private health insurance to pay for it. But, if you buy privately, you don't get the subsidy. You are on your own. Otherwise, it really is a two-tier system. Just the way public school taxes go to pay for public schools, not as a contribution toward the cost of private schools from which most are excluded." So roi you want only the well-off to get quality health care and good schools, and everybody else to get mediocre government health care and worse government schools. Schools run by nitwits, staffed by incompetents, and producing kids who are unemployable. Your claim that most are excluded from private schools is utterly dishonest. The exclusion is due to the power of the teacher's unions who prevent poor children from getting vouchers to attend private schools. The teachers' unions are greedy, shameless pigs who are the number one enemies of America's children They deserve the contempt of all decent Americans. Don't you think the working classes in this country deserve better than that?
- bulbman1066
June 1, 2011 at 11:50pm
Paraphrasing bulbman: Four legs...er, I mean, private sector good, public sector bad. You have no idea what you're talking about bulb. Here in Australia we have a dual public/private sector health system. (I work as a doctor in both.) If I wanted to get an elective knee replacement without a wait, I'd happily look to the private system. But if I was sicker than stink and in need of somebody to keep my worthless carcass on this side of The Great Divide, I know which hospital I'd choose, and it ain't the private one.
- AaronW
June 2, 2011 at 12:15am
bulbman, you really have not the slightest idea what you are talking about and just make things up at will ad nauseum. You are not even dishonest, bulbman. You are simply in a fantasy world of your own creation that has NOTHING to do with what is going on here on earth. Yes, it is impossible for most people to afford private school tuition, even with the financial aid available. No, that has nothing whatsoever to do with teachers' unions as private school faculty are not unionized. Did you not know that? The point of not allowing public funds to subsidize private education is that private education is not available as of right. Hence, the subsidy would merely make it cheaper for those who can afford it leaving those dependent on the public schools even worse off. The entire point of having all but the wealthiest depend on a single system is so that we do not have a two-tier system in which the poor are left with the mediocre. Vouchers would be fine if private schools had to accept the voucher as payment in full and places were assigned by lottery so that everyone had the same opportunity to attend. Otherwise, vouchers fund a racist and economically discriminatory system. Do you, for example, have any idea about the demographics of higher education? No, the question answers itself because you have no idea about anything at all that is actually occurring in the real world. Not a blessed thing. There is no reason why we cannot have privately operated health care, or a mix of public and private, if the role of the demand side is played by government. That is, medical protocols determine what care is provided to whom under what clinical circumstances and the government sets the price based on a standard cost system. This makes medical providers price-takers, eliminating their now huge market power. Just like any other market, the supply then adjusts. Those who can provide the services efficiently make more money. Those who are too inefficient go bust. Anyone who wants to write the check and buy private care is welcome to do it, but since almost everyone depends on the publicly financed system, there is a political check on cost and quality. I was treated at a public hospital in France. The wait was zero, the service was great, the cost, even without insurance, was comically low. It cost me $100 for a procedure that would have been 15 times that in the US. By the way, bulbman, and in that vein, the biggest reason we have mediocre public schools is local financing. This allows the well-to-do to have the schools they want, essentially publicly funded private schools just as you envision, without having to concern themselves much about the schools that serve everyone else.
- roidubouloi
June 2, 2011 at 3:37am
To finish the thought, bulb, public schools in wealthy school districts are often if not always superior to the best private schools. If I had the option, I would send my children to Scarsdale High School or Roslyn High School (the one I attended when the world was young) in preference to any private high school in the United States.
- roidubouloi
June 2, 2011 at 3:43am
My argument isn't against the idea of "health care realism" per se - but in actuality - regardless of who is making the decisions - it's likely to be wrong. People themselves and/or their families have to ultimately be the deciders. I don't want to be part of a system that decides, ipso facto, that children are more valuable than grownups. That is exactly like the idea that fetuses are more valuable than living women. There are plenty of people over 80 who are still contributing. Not all are geniuses but some are. Regardless, these old people are often loved and valued by their communities and their families. What kind of society would deny them the right to life?
- Sophia
June 2, 2011 at 4:23am
It is a false dichotomy, sophia. How much should society pay for one week to one month of life requiring the labor of many highly skilled people? A million dollars? Ten million? We have finite resources. We are compelled to make choices. The choices should be made thoughtfully. Would anyone bankrupt their families for a month? I doubt it. But what if our collective decisions, because it is not our family that pays but all families, is doing just that?
- roidubouloi
June 2, 2011 at 7:14am
"But what if our collective decisions . . . are doing just that?"
- roidubouloi
June 2, 2011 at 7:15am
"People themselves and/or their families have to ultimately be the deciders." Sophia, everybody dies. What's more, the overwhelming majority of octogenarians will die soon, almost all within ten years, and if you limit your consideration to those octogenarians dealing with medical diagnoses serious enough to require expensive treatment, most will die within two or three years--with or without treatment. Let's work through a hypothetical. On rare occasions people develop coagulation disorders late in life, sort of like hemophilia but not hereditary. They can develop antibodies to their own coagulation factors that block those proteins' action and promote uncontrolled, life-threatening bleeding. Let us suppose that an 80 year old man develops such a disorder. Let us also suppose that he suffers from some other common chronic diseases including early Alzheimer's and stenosis of the aortic valve. Finally let us suppose that there exists a treatment for the bleeding disorder in the form of a recombinant activated clotting factor that will keep the bleeding under control. The catch is that the treatment, which will be required for the remainder of the patient's life, costs a million dollars a year. I ask you, should he receive this treatment? And who is really in the best position to decide this question? The patient? His wife? Do you honestly believe that? The problem with leaving the decision to the patient is that from the patient's perspective the decision is a no-brainer--at least so long as somebody else is footing the bill. If he doesn't take the treatment he dies right away whereas if he does take treatment he goes on pretty much like he has been. Assuming he is not actively suffering (yet) from his dementia and his aortic stenosis, why wouldn't he accept treatment? Anyone in his position would. But from a societal standpoint it's not nearly so simple. The man's actuarial survival is severely limited. His bleeding disorder precludes valve-replacement surgery to fix the AS and as a result he'll almost certainly die within two years. Moreover, his incipient dementia places limits on how productive he can be during his remaining time and even on how much pleasure he can take in life for its own sake. From anyone's perspective besides the individual's is it really a good use of 2 million dollars to extend a cognitively disordered man's life from 80 to 82? Think about what that money really means. It didn't fall out of the sky. What that cost means is that a number of scientists and venture capitalists devoted years of intense intellectual effort upon the invention of a treatment--not a cure--for an extremely rare bleeding disorder that effects people late in life who are likely to die soon of other causes. Was this really the best way for these people to focus their talents? Might it not have made more sense--from a societal perspective--to encourage them to use their expertise in molecular biology to develop genetically-engineered algae that can produce hydrocarbon fuels from sunlight? The thing is, if you say the individual has the "right" to demand every possible treatment no matter how marginal the benefits in terms of QALYs saved and to demand that society as a whole pay for that treatment--and whether you're talking about single-payer or private insurance, ultimately it's society as a whole that pays--then science's best and brightest are going to spend their careers figuring out how to win seniors a few more rounds of golf. They will inevitably go where the money is.
- AaronW
June 2, 2011 at 7:47am
Roid writes: " That is, medical protocols determine what care is provided to whom under what clinical circumstances and the government sets the price based on a standard cost system." Why don't we set housing prices based on a standard cost system? Housing is more important than health care. PS. No, rent control hasn't been successful in controlling costs.
- seattleeng
June 2, 2011 at 4:04pm
The problems are completely different as medical care is a production process and the rental market largely is no (only at the margins in terms of new units). Many rental properties will rent for more than their cost of production, the very economic definition or a rent. There is no reason for the price of medical care to exceed its cost of production. The whole problem with medical care is that there is no means of establishing a functioning market on the demand said unless we are willing to allow care to be allocated on the basis of willingness and ability to pay. As well, the need for medical is technically determinable based on medical condition. Thus there exists an independent basis for determining the quantity that should be consumed. There is no comparable way to manage the housing market. Medical care is not a normal good. Its importance relative to housing or anything else is quite irrelevant.
- roidubouloi
June 2, 2011 at 6:09pm
bulbman: "Government doesn't provide most goods and services, the private sector does, and there's a reason for this. Government is a high-cost, inefficient provider." Yes, generally I want the private sector providing goods and services. But where there's evidence that the private sector is not a good provider, then there's no reason not to have government intervention. And the evidence is abundant in the health care field, where all our peer nations get comparable results to the US while spending a third less to half as much as we do. In addition, the private market in the US for health care is far more expensive than Medicare or the VA system, which by all accounts does a pretty good job. At some point, free market fundamentalism has to give way to facts. If market mechanisms worked so well in health care, I'd be all for it. But I'm not going to depart from reality just to satisfy some ideological commitment.
- dsimon
June 2, 2011 at 10:52pm
Roid writes: "Medical care is not a normal good." Indeed it is. Your house and the upkeep thereof are 100% a function of your ability to pay. Just like medical care. Shelter (healthcare) is an expensive investment that will take a fair % of anyone's pay. Generally, you assume the maintenance and upkeep (checkups) on your house (body) is required, and that will require extra money to keep your investment (house or body) safe. And you hope it doesn't happen, but if an unforeseen event occurs such as fire or flood (cancer), you have insurance on your house (body) that will cover that. This is very much exactly the same as healthcare. It goes further in that a plumber (doctor) to fix your house (body) is licensed and regulated by the state. And more plumbers (doctors) is generally better because it lowers prices for consumers. We also have special plans for those that cannot afford adequate shelter (healthcare) that kick in if you earn too little money. The similarities are striking.
- seattleeng
June 3, 2011 at 11:09am
As usual, seattle, you have misconceived pretty much every aspect of the problem. I don't have time right now to disassemble your post in detail. Until I get to it, you can think about these differences between medical care and other goods: 1. The medical care one needs is not based at all on choice. Sure, there are frills and luxuries in medicine, but, for the most part, the care one needs is determined entirely by medical condition. You can live in a small house or apartment, drive a small car for years, wear out your clothes, by bulk food. But you cannot have half of a surgery, or cut your prescription in half to make it affordable. 2. Individuals have little ability to make technical judgments about the adequacy and quality of medical care. 3. It is not the case that medical care is generally affordable with exception of a segment of society whom we could service with subsidies, as you describe above. The cost of medical care is rapidly becoming unaffordable for the entire society. 4. The insurance to which you so blithely refer by analogy to home insurance is the problem, not the answer. It is because medical costs are hugely unevenly spread, based on condition, that almost all of it needs to be insured, as if 10% of the population in any given year is going to have housing costs and the rest will have none. But the insurance means that the marginal cost to the individual is at best a fraction of the marginal cost to the supplier. Hence, the market cannot achieve an equilibrium in the normal way. The only way to have a functioning demand side would be to have willingness and ability to pay govern what is purchased. But then people without the means would not get health care. You think about all that, seattle. I'll come back later and finish the job.
- roidubouloi
June 3, 2011 at 4:12pm
Roid, Nothing stops a person from living in a tent. If a bad storm comes, or a cold spell comes, they will die. It's that simple. Thus, not wanting to die, the tent dweller decides to allocate a larger part of his income to better housing. And voila, he can survive storms. Why is health care any different? If somebody has devoted an adequate % of their income to health care, they will have excellent medical care. Now, you can argue that health care has become too expensive. That is true. But to argue that health care is so unique from everything else that it requires special attention outside of the free market is silly. There are plenty of privately run health care plans around the world where everyone is covered.
- seattleeng
June 3, 2011 at 11:53pm
seattleeng: "But to argue that health care is so unique from everything else that it requires special attention outside of the free market is silly. There are plenty of privately run health care plans around the world where everyone is covered." seattleeng, I know you've read T.R. Reid's "The Healing of America." Consequently, you must know that in our peer nations where everyone is covered under private insurance, those insurers are legally mandated to be nonprofit, and they are highly regulated. And all of those nations have a mandate. I don't think those examples constitute the "free market" you espouse. If you have examples to the contrary, please provide. China recently tried a free market health care system. http://www.pbs.org/newshour/bb/health/jan-june11/china_04-14.html It quickly became very expensive and left many people without access to care. There is ample evidence that free market principles just don't apply neatly to the health care field. (In case you missed it, here's an article on a study that concluded that having more "skin in the game" does not lead to more efficient use of services, http://www.kaiserhealthnews.org/Columns/2011/March/032911cohn.aspx)
- dsimon
June 4, 2011 at 1:35am
I probably shouldn't waste my time responding to you seattle at all. I'll try to keep it brief. Yes, if a fire burns your house to the ground and you find yourself underinsured and short of cash to replace it, you can choose to live in a tent--like the guy in "Hung." And that is PRECISELY ROID'S POINT. In the housing market the buyer has the option not to buy. In most circumstances no such option exists in health care. Next time you have an ST-elevation myocardial infarction and the cardiologist tells you that you need emergency bypass surgery now, not tomorrow, NOW, try exercising your right of refusal and tell me how that works out for you. And, yes, given average lifetime health expenditures in the U.S. of around a quarter million dollars most workers could cover that nut if they started putting money aside from the moment they first earned an income. But because that health liability is not distributed uniformly--some incur $30,000 in charges over their lifetimes, others $3,000,000, there has to be an insurance system, and the insurance system has to be regulated in such a way as to force people to participate, otherwise it fails. Too many people exercise their freedom to opt out when they're young and healthy and don't see the need for insurance, and then either they remain uninsured later in life when they get sick and die without treatment or else the insurer goes bust because of the adverse risk distribution of its insured pool. There is ample evidence that the most efficient way to organize this kind of universal insurance is to have a single payer and have it funded through taxation, but if you're wedded to private insurance I can wear that--but you HAVE to have a mandate. Otherwise the system will fail for the reasons I outlined. You can't have it both ways, you can have a truly free market for health care and health insurance, but then you'll have people dying because of their poor foresight and lack of discipline when it comes to saving in their youth and early middle age. You'll probably say, "Serves 'em right." If so, I can only respond by suggesting that if you were a mensch you wouldn't think in such a vicious way.
- AaronW
June 4, 2011 at 3:00am
AaronW: "you can have a truly free market for health care and health insurance, but then you'll have people dying because of their poor foresight and lack of discipline when it comes to saving in their youth and early middle age." I'll go further than that. You'll have people dying even if they had good insight and discipline, because many people don't have jobs that provide health care benefits and don't pay enough to be able to purchase anything substantial in the private individual market, which as everyone knows is far more expensive than group and other "socialized" plans. Even people with the means to buy on the private market can have substantial difficulty doing so, at any price. It is amazing what some insurers will consider a pre-existing condition: a corn, a cataract, can result not just in absurdly high premiums but complete denial, at least according to this op-ed story from the NY Times, http://www.nytimes.com/2011/02/20/opinion/20Dubinsky.html (though I fully admit that an anecdote does not constitute data). You lose your job, your kid has leukemia, and you most likely won't be able to get insurance no matter how responsible you've been. For-profit private insurance puts incentives in the wrong places: insure only those who are healthy, deny benefits wherever possible. There are reasons why the unregulated market doesn't seem to produce good health care outcomes, and experience seems to bear that out. Why experience doesn't seem to get free market adherents to at least question their assumptions is a mystery to me.
- dsimon
June 5, 2011 at 9:46am
The $600 million that Flexner had to improve health education in 1910 was about the same part of the U.S. economy as $250 billion would be today. Probably beyond the reach of even the Gates Foundation.
- jonrysh
June 5, 2011 at 3:22pm
The authors make a rational case to support the conclusion that "The ethic of medicine has long been inspire unbounded hope in the sick patient and the same kind of hope in medical research. Sobriety and prudence must now take their place." Callahan and Nuland have probably seen enough of the unpleasantness that takes place at the end of life to reject the same outcome for themselves. But would they do the same for someone near and dear to them -- a spouse, friend, child, aunt, uncle --; that is, talk the critically ill patient into rejecting advanced medical treatment? Or would they say, "Your fellow citizens have paid enough for you. If you want more treatment, pay for itself or get a family member to pay it for you." Whatever happened to Hope? Or was that just a come-on campaign slogan?
- BU4691
June 8, 2011 at 5:40pm
Despite ones political leanings, we must all recognize that we are approaching the point where we must decide as a society how we are to prioritize our health care costs. The days of essentially unlimited access are drawing to a close. We should start by educating ourselves as to the real reasons for the rise in health care costs, as well as what one can reasonably expect from treatments. We haven't had enough of these discussions, but have instead argued ad nauseum over whether or not 'death panels' exist. As an anesthesiologist I encounter virtually every specialty in the inpatient setting (surgery, radiology, ICU, etc.), and all too frequently see futile care applied for no reason perhaps other than the fact that it's available. We need to recognize that we ALL DIE, and that if a treatment cannot reasonably extend or improve the quality of life, then maybe it should be withheld. I hope that critics of Dr. Nuland's essay do not take from it that the elderly or sick are not worth our attention and money. They are, but we must begin to discuss what is reasonable and just care for our elderly; our current system does not accomplish this on the whole.
- dmtrousd
July 20, 2011 at 11:08am