by Bruce Goldman
The U.S. health care system, although it’s the costliest in the world, doesn’t even deliver the goods when it comes to delivering health. That’s the conventional wisdom. But is it true?
At least a few well-researched studies by credentialed and respected experts suggest we might want to pause to consider whether, in the mad dash now underway to fix our ailing health care system, we could inadvertently end up breaking parts of it that work very well.
Money down the drain?
Let’s start with a claim we’ve been hearing a lot lately, summarized as follows: High-tech treatments and procedures (MRI and CT imaging, sweeping use of pricey meds, etc.) cost a fortune, yet produce no substantial treatment gains and carry little preventive payoff.
Here’s a study, by University of Pennsylvania scholars, showing that five-year survival rates in the U.S. for cancer and heart disease are the world’s highest, due not only to earlier detection but also to more-aggressive treatment of these conditions once they’re caught.
And then there’s a National Bureau of Economic Research analysis whose author looked state by state and found that the more a state was characterized by high usage of sophisticated diagnostic imaging, the greater the longevity within that state. According to the study, this was a causal relationship, not an artifact (such as richer states having healthier people and more high-tech equipment).
No doubt there’s a whole lot of prescribing and imaging going on in these United States, and some of that — maybe a lot of it — is wasteful. But there are reasonable ways of dealing with this short of a complete overhaul. Why not ban self-referral (i.e., to a diagnostic facility, by a physician who owns a piece of said facility). How about reforming American tort laws, whose financial costs to the health care system far exceed the direct-litigation expenses because medical practitioners prescribe diagnostics and drugs out of fear of malpractice suits, and because specialists’ sky-high malpractice insurance premiums are passed on to patients.
Life in the U.S.A.: Short, nasty, and brutish?
Finally, what about the claim that “U.S. life expectancy falls short of that in other advanced countries, no doubt as a result of our broken healthcare system”? After all, there’s no primary endpoint like death, is there?
Health economists Robert Ohsfeldt of Texas A&M and John Schneider of Health Economics Consulting Group dispute the widely held assumption that Americans’ substandard life expectancy reflects the poor health care served up in this country. They found that, once you factor accidents and homicides out of the picture, U.S. longevity is unsurpassed. As reprehensible as our high murder rates are, they can’t be construed as an indictment of the American health care system, can they? (And if they can, what in the bills now worming their way through Congress would change this?)
Also dragging on America’s calculated overall life expectancy is what all acknowledge to be a relatively high infant-mortality rate. The presumption is that this high rate probably stems from an abundance of preterm births attributable, in turn, to mothers deprived of prenatal care. That’s a plausible claim — but one confounded a bit by a recent March of Dimes white paper, which flags high and increasing rates of preterm births in the United States — and in Canada, and in Sweden, and in Denmark, countries seldom accused of neglecting pregnant moms.
An alternative hypothesis is that high premie rates could reflect older would-be parents’ rising resort, in economically advanced countries, to fertility-assistance techniques. And America’s infamous high reported infant-mortality rate is to no small extent the product of the heroic efforts now routinely made (certainly in the United States, as any neonatologist specialist can attest) to rescue premies that, in past days, would have been logged not as dead infants but as stillbirths.
Expensive? No question. Inefficient? Maybe. But, just maybe, those bucketloads of bucks we collectively throw at our medical problems aren’t going entirely down the drain.
Bruce Goldman covers immunology and infectious disease, neurosciences, cell biology and biochemistry on Scope at the Stanford University School of Medicine.
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{ 9 comments… read them below or add one }
Small bill, anyone?
I’m really surprised this post isn’t getting more comments.
This poster points out a very big lie that is being promoted, mostly by the left, and for obvious reasons. The worse you make the US system look, the more you can justify tearing it up.
I have heard multiple times that if you eliminate accidental deaths and murder, that the US system does very well. In many types of cancer survival, it is number one.
I have looked at the WHO analysis of health care ’systems’ and find it to be silly. They measure and report all sorts of things that have nothing to do with how we commonly view analysis of a health care system. Indeed, there is an inherently socialistic perspective built into their analysis and results. And yet this is the most quoted study?
I have asked myself how I would analyze a health care system – and the answer is not easy. We all crave standardization where it is very difficult to come by. Genetics, life-style, environmental factors, etc. can all bear on the equation. How should one measure a health care system? It is simply not an easy question to answer. Should you measure access to health care as part of the ’system’? If 20% of people don’t get the ‘best’ the country has to offer, 20% get the ‘best’, and the rest something in between – how should that be quantified?
These are difficult decisions, but suffice it to say that if you take a certain well-defined disease (like cancer type x), the US is actually the leader. This can be important if you are someone of means who wants to know where to go to treat your particular type of cancer.
And of course, other countries wouldn’t be as good as they are, without the contributions from the US. The US (along with a handful of other countries) pushes the treatment and diagnosis envelope – especially creating new drugs which benefit the world. Cut off that spigot and the world will suffer right along with us.
Would people stop quoting survival rates. If your going to call into question suspect date points like life expectancy and infant mortality rates you have to be equally skeptical about survival. In the medical community mortality rates have, and will always be the definitive metric. You don’t hear those quoted very often by defenders of our system. Do you know why? Because across nations they don’t vary nearly as much as survival rates. And I refer anybody who thinks “more medicine is better medicine” to the Dartmouth Atlas Study.
So lets assume our healthcare system is the best.
It is also by far the most expensive.
How are we going to keep paying for it?
Family Practictioner said “So lets assume our healthcare system is the best. It is also by far the most expensive. How are we going to keep paying for it?”
By taking the ‘we’ out of that question. Health care should be an individual responsibility, not a group duty. How are you going going to buy your groceries, or obtain your auto insurance? Look at the current republican proposals for health care reform or read the CEO of WholeFoods ideas for better ideas on how to fix the system.
David’s comments may sound good in a college debate but in reality they are useless.
David:
An otherwise healthy 40 year old man goes to an emergency room and is diagnosed with appendicitis. He is told he needs surgery but says he is broke and cannot pay for his surgery. What should the doctors and hospitals do? Demand payment up front? Turn him away? Tell him to go home and get peritonitis and die? How about a woman about to deliver a baby?
The truth is that health care does not obey simple supply and demand dynamics. A lot of people receive assistance to buy their groceries. Are you against that? Should people go hungry?
Simple Ayn Rand platitudes do not answer these questions.
Family Practictioner,
I agree that these situations are complex. I am not an advocate of reductio ad absurdum. But neither am I an advocate of out of context examples such as your own which don’t address the whole system, how we got here, and how we can improve the situation. For good ideas please read Mackey’s essay (http://www2.wholefoodsmarket.com/blogs/jmackey/)
To address, none-the-less, your specific examples, the doctors and hospitals may establish their own principles and approaches to this situation – taking on the young man as a charity case if they like (which would be the most common answer, and which is what I would do.) Many people would (and probably should) consider this as the cost of doing business in an emergency setting. The situation with the pregnancy involves (probably) more culpability – but again, the approach would be designed by the hospital and physicians involved. Wouldn’t that be your answer?
But, since you mention Ayn Rand, I will point out that she was not an advocate of such “life boat” approaches to ethics. You know, the analyses that start out with three people in a life boat with only food enough for two. They tend, by design, to eliminate all the important elements of actual morality (personal responsibility, context, the separateness of individuals) and then try to design a morality around this. Underlying the entire approach is always an appeal to the altruist ethic of self sacrifice. The underlying view is: you don’t have the right to exist for your own sake, and if anyone is in need, by that very fact, they have a claim on your life. Instead of recognizing that, in general, benefit for one person does not mean injury to another – they set up unusual circumstances in which conflict is inherent – and the choice becomes: kill another or sacrifice yourself.
I am not against people getting assistance to buy their groceries. I am certainly against one group of people forcing another group of people to give up their money or property in order to buy groceries for yet another group of people. It is not charity that I am against but the use of force against the innocent. Give away all of your money to buy someone’s groceries, if you like – but keep your hands off my money, time, and effort. If I want to give them away, that should be my decision.
David:
Charity care is not free.
When doctors and hospitals extend charity care, the cost for it has to come from somewhere.
It sounds like you would accept a situation where a hospital turns away a case of appendicitis due to inability to pay provided that they were in no position, or mood, to extend charity care.
I for one do not think it is such a good idea. Doctors and hospitals are being squeezed, and such charity will not last forever.
I wish health care obeyed basic principles of supply and demand, but it does not.
By the way, my real life example of a case of appendicitis is a lot more relevant than your obtuse story about 3 people on a life boat. I don’t get it, quite frankly, although I did have you pegged as an Ayn Rand fan.
Family Practitioner,
I think Mackey’s essay has some good ideas.
I know that charity care is not free and that hospitals are being squeezed, but the answer as to how/why this is occurring is complex and, I think, beyond the scope of this forum. Suffice it to say that the ‘third party payer’ system, including the massive intrusion into the market of the government (in the form of Medicare and Medicaid) has certainly undercut the possibility of a normal market, even if you don’t feel that a normal market is possible. The government spends 50% of all heath care dollars spent in this current ‘market’, distorting it in countless ways along the way. Those who advocated and pushed for Medicare have created a massive unfunded liability, a large dependent class of people, and destroyed the market for the elderly in health care. It threatens to bankrupt the nation. Nice job. One answer to getting us out of this mess is not further intrusion by the government – but a slow phase out of Medicare – say increasing the age of eligibility by 6 months each year, until almost no one is eligible.