Article — From the February 2009 issue

Sick in the Head

Why America won’t get the health-care system it needs

( 3 of 12 )

rationing

No one doubts that fixing the health-care system is going to require someone to make difficult choices. In 2006, Americans spent $2.1 trillion on health care—at $7,026 per person, more than any other nation—and yet we lag far behind other nations in such measures as infant mortality, life expectancy, and early detection of life-threatening illnesses. This bad bargain is irritating, of course, but, more important, it is also unsustainable. Aging baby boomers will increase their demands on the Medicare system even as the government faces the revenue shortfall that will result from their retirement. Employer-based health care, meanwhile, is increasingly unaffordable, causing many companies financial distress. And even as the cost of the system goes up, a growing number of Americans are being left out of it entirely.

The word for making such choices, so often unsaid in American politics, is “rationing.” All health-care systems, no matter how wealthy, require some form of it, because advances in technology always outpace the ability to pay for them. But there are (at least) two ways to decide who gets what in a health-care system. One of them is to let the market sort it out: those with the most money get the most care. The other is through triage: society seeks to determine, within a given budget, the most effective treatment for the greatest number of people. The difference between these two approaches is significant.

We tend to think about systems in terms of our personal motivations. But systems have their own logic. A market system may be driven by individuals or corporations seeking profits, but the primary function of the market itself is to grow. That is why growth, not profit, is the conventional measure of economic health. Similarly, a health-care system may be driven by individuals seeking to improve their own health, but the primary function of the health-care system itself is (or ought to be) to ensure the overall health of society. Within each realm, these goals can sometimes be in conflict. The success of banks at maximizing profits for a time by extending shaky loans to prospective homebuyers, for instance, has resulted in a recession (i.e., negative growth). Similarly, individuals acting on various beliefs about health care—say, that vaccination leads to autism—can cause the health of society as a whole to decline. More important, though, is that these two realms themselves be understood as independent. Societal health and economic growth are not mutually exclusive, but they are in tension, and when we confuse one with the other, problems occur.

In Overtreated, Shannon Brownlee argues that the major problem of health care in the United States is not that there is too little but that there is too much. “We know that people who don’t get enough care have a higher risk of death,” Brownlee told me. “About 20,000 Americans die prematurely each year from lack of access. But getting unnecessary care isn’t any better for you. In fact, about 30,000 Medicare recipients die each year from overtreatment. This sounds counterintuitive until you think about the fact that practically any medical treatment you can name poses some risk.” For instance, doctors regularly test prostate-specific antigen levels in men to see if they have early signs of prostate cancer. As Maggie Mahar, the author of Money-Driven Medicine, explained it to me, this sounds like due diligence, but in fact the National Cancer Institute does not recommend routine PSA testing, because the majority of older men diagnosed with this slow-growing cancer will die of something else before they experience any overt symptoms, whereas if they are treated for prostate cancer, many will experience such side effects as erectile dysfunction, incontinence, and sometimes even death. “When I was at a conference in Berlin last spring, doctors from other countries were shocked that we still do routine PSA testing,” Mahar said. Why do we do it then? “Urologists stand to gain. The prostate-testing market is worth $200 million to $300 million annually. And no doubt many urologists believe they are saving lives.”

Overtreatment, of course, is another word for growth, and it is the natural consequence of a market-driven system. A triage approach, meanwhile, would save money, both by removing some (though not all) of the incentive to overtreat and by simply eradicating the massive bureaucracy that currently is required just to figure out who is paying for what. Physicians for a National Health Care Program notes that “private insurance bureaucracy and paperwork consume one-third of every health care dollar” and that going to a single-payer system “would save more than $350 billion per year.”

So the mystery remained. Why is single payer off the table? At Conyers’s meeting, it was Dr. Zarr who presented what at first seemed to be the most plausible theory. “You’ve got to get rid of the middleman,” he said, “and that middleman is the private health-insurance industry. And they have got to go.

is a senior editor of Harper’s Magazine.

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Commentary January 31, 2010, 11:08 am

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