Docs rant all the time about what smokers cost “the system”. I have known too many smokers to graciously die of CA shortly before collecting social security to buy that argument. We always talk about “lives saved” by this or that as if somehow, the final mortality rate had been reduced to something less than 100%.

It reminds me of the cost savings argument that the governor of Texas gave for mandating Giardiasil vaccine–when in fact it turned out that the cost of vaccinating every girl in Texas would cost ten times as much as is spent on treating cercival cancer there. It may save lives–or may not–but it will not save money. But the belief is so strongly rooted in our mindset that he didn’t even look at or ask for the numbers.

It isn’t the guy snarfing moon pies with nicotine stained fingers while he misses his doctor’s appointments to squeeze in another (heavily taxed) shift dragging down the system. It is the work out queens and health nuts who run to the doctor for everything, want to live forever, keep all their appointments and followups, and get every single recommended test and procedure.

The civic hero is the 100 pound overweight chain smoking businessman who croaks just before or after retirement giving the state a nice pile to loot in estate taxes. Grasshoppers live longer than ants.

Provide no care at all beyond vaccines and the lost productivity is a pittance compared to what is saved by shortened periods of disability and dependence and shorted retirements–a period of negative productivity.

The data is all there for anyone to look at if they care to. The problem is that the opposite has been proclaimed, with no basis in evidence, for so long that most people just take it for fact and are too lazy to think for themselves. We spend tremendous resources and structure whole areas of policy on false beliefs and are then surprised at the consistent failure to get the expected results.

Those who survived childhood in 1900 lived to an average age of about 70–past the retirement age, so really we are not doing much on the whole to keep people productive.

The reductio ad absurdum for this is to imagine the cheapest possible health system.

That would be “live until you die.”

There may indeed be an optimal level of spending such that morbidity and mortality are decreased to a theoretical minimum. But my guess is that optimal level is destined to remain only theory. In practice, any intervention will be costly but an intervention that prolongs life will inevitably be more costly as it increases the area under the “life with morbidity” curve.