Health care costs

I've been listening to a lot of bloviation regarding health care reform lately. Some of the arguments are patently illogical*, others are simply misinformed, but everyone pretty much agrees something must be done because health care costs are one of the things killing the American economy. One of the reasons the U.S. auto manufacturers moved production to Mexico and Canada was to avoid paying health benefits, which add over $3000 to the price of each car that rolls off a General Motors assembly line in the U.S.

Health care costs are also a major driver for bankruptcy -- I remember reading not long ago that over 60% of the personal bankruptcy cases filed in this country can be traced back to medical expenses. We keep hearing that the U.S. spends a lot more on health care as a percentage of GDP than other industrialized nations, yet we have worse outcomes: higher infant mortality rates, for example, and shorter life spans. The infant mortality rate in Sweden is 2.75/1,000 births; it's 6.3/1,000 here. The Swedes, with their evil socialized medicine, are obviously doing something better than we are.

We also hear a lot of garbage about what's driving up health care costs. Right now the favorite thing to blame, the handiest target, is the so-called obesity epidemic. It's fat people causing the problem -- if we can just get them all to eat lettuce leaves instead of Godiva chocolate everyone's insurance premiums will magically drop. Right. And squadrons of flying pigs will end the conflict in Afghanistan by shitting on the Taliban.

The things driving up health care costs are many and diverse, but fat people aren't one of them. The actual factors include:

1. Administrative costs. The typical private insurance company has administrative costs well over 30%. In contrast, Medicare's administrative costs run about 2% -- because, among other things, Medicare isn't paying out multi-million dollar salaries and bonuses to CEOs and upper management executives.

2. Technology, and the equivalent of an arms race between health care providers. Clinics and hospitals all want to have the latest toys, the most recent model of an MRI or a PET or CAT scan equipment. Once they've got them, they (a) have to steer as many patients into them as possible and (b) have to advertise like crazy to attract even more patients. Why settle for a $50 chest x-ray if you can persuade someone to get a $2000 CAT scan? In a sane world, hospitals and clinics would cooperate on high tech, there would be regional imaging centers, and economies of scale could be practiced. In our world (definitely not a sane one) every hospital pushes its own imaging center, every hospital administrator worries about paying for the damn thing, and all patients get pushed into having high dollar scans they don't actually need.

Even relatively low tech procedures are over-prescribed in an effort to help the hospital's bottom line. Example: mammography for breast cancer. American women are told to start at 40 and get one yearly; in most European countries they start them later and do them less frequently -- and the cancer detection and survival rates in many of those countries are better than here. (Of course, one of the reasons the survival rates are better is that patients in Germany or Sweden don't have to hold spaghetti dinner fundraisers to help pay for their treatments, but that's a slightly different issue than what drives up costs in the first place.)

3. End of life care/unnecessary and/or unrealistic procedures. This is a hard one to talk about, but the reality is the American fear of death is pushing health care costs up. As a society we spend tremendous sums of money on people who, to be very cold about it, are already quite close to the end of their natural life spans, no longer have much productive value to society (they're retirees), have enjoyed many good years already, and if subjected to medical interventions are quite likely to experience a diminishment in quality of life. Ask around. Every senior citizen can cite an example of someone they knew who had "routine" heart surgery (usually by-pass), sailed through the surgery just fine, and then suffered a post-operative stroke and is now in a nursing home. Statistically the surgery was successful (the patient survived), but it's a double whammy to health care costs: high dollar surgery followed by months or years in a skilled nursing facility.

Barbara Bush is a classic example. The woman is 83 years old, her aortic valve was following a perfectly normal pattern (stiffening with age), but rather than accept the inevitable (she's going to die eventually) and treating the problem the way it would have been not many years ago (learning to live with the shortness of breath, avoiding activities that aggravate it), she gets a replacement part. Well, what about the rest of that 83-year-old body? Assuming she makes it past the post operative stroke risk window with no problems, now that she's on blood thinners and anti-rejection meds (and she is, because once you've got a pig valve you're on both forever), her quality of life is dropping anyway. How long before she trips over a rug or bumps into a piece of furniture and discovers the joys of having been turned into the equivalent of a hemophiliac?

I've heard of people in their 90s having similar surgeries. Whatever happened to telling people frankly that they now have a condition that may limit their activities, yes, it's probably going to kill them, and here's some digitalis or nitroglycerin to help them manage until then?

One of the bogeymen of health care reform is the specter of "rationing." The argument is that if we had a national health care system, we'd have "rationing." Well, maybe we should. If we individually are too burdened by emotion to deal with reality, then maybe it's time for society to collectively to step in with a reality check that says, yes, it's sad that this particular person in this particular time and place is running out of time, but no one lives forever.



[*Patently illogical: The right wing line that "Health care is a problem best solved by the private sector, i.e., insurers and HMOs." Just who do the Republicans think is running the health care system now? It's been primarily private sector, the magic of the marketplace, for the past couple hundred years, and we can see how well that's all worked out.]