Why we won't fix health care

The American health care system is insanely complicated. It is dysfunctional and corrupt in many ways. But there is one simple reason that it is so much more expensive than the systems of similarly well-off countries, and that is that we lack a mechanism for controlling spending.

By and large U.S. health insurance companies pay for the interventions that doctors prescribe, and U.S. doctors prescribe pretty much everything that can be justified. This is partly because most doctors work on a fee for service basis: the more diagnostic tests and interventions they order, the better their take-home pay. But it is also partly because this is what patients demand. When we are broken we want our physicians to pull out all the stops in an effort to make us well again.

This is easy to sympathize with. Health is a big deal. The problem is that today- compared to even 50 years ago- doctors can do a heck of a lot. They will be able to do even more tomorrow. That is the main reason why our health care premiums have been rising and why they will continue to rise without a dramatic change in the way that health care is administered.

In a sense it is odd to call this a problem. We do not complain much about the fact that the money we spend on home entertainment and dining out has gone through the roof during the last 50 years. There is nothing wrong with paying a larger portion of our budget for X if what we want (or need) is more X. That’s how things are supposed to work.

The real problem, then, is that, unlike Super Mario and Banh Mi sandwiches, most of the new stuff that medicine offers to suffering patients isn’t that great. (Of course, some, like artificial joints and cataract surgery are miraculous.) When someone has a chronic or life-threatening condition that resists standard treatment options, ordering every possible test, trying every possible medication, procedure or surgery tends to produce roughly the same result as doing nothing. (Sometimes, in fact, far worse.) This is simply because there is a world of difference between a possible outcome and a probable one.

At bottom, every country that has dealt effectively with this problem has found a way to tell very sick or broken people that certain medical interventions aren’t worth the money. Americans are not comfortable with this. Faced with the specter of socialized medicine, conservatives convulse at the prospect of death panels. Faced with market-based approaches that would encourage individuals to shop for the best value, liberals bellow about the moral necessity of equal access to the highest quality of care.

The political histrionics belie a fundamental agreement, viz., that we all want a health care system in which everyone, no matter how ill, how old, or how effective the available options, gets the full monty. Of course, we do not have anything like such a system, but the fact that we aspire to it is one of the main reasons it is killing us. And I don’t mean this figuratively. As health care consumes an ever-increasing percentage of personal, corporate and public budgets, the money available to do other things that save lives and promote well-being (education, infrastructure, public safety) dwindles proportionally. And the more we insist on an absolute right to treatments of little or no value, the less we are able to promote preventive practices of proven value.

What makes this problem particularly acute is that we, like every other industrialized country, have an aging population. People in developed countries are living longer and reproducing at ever decreasing rates. Hence, every year that goes by, the percentage of old people rises. Old people break constantly, and thus require medical attention and hospitalization far more often. This means that escalating health care costs are in large part due to our commitment to (a) keeping a growing percentage of old people alive as long as possible, committing us to (b) the use of expensive and ineffective means for doing so and, consequently, (c) spending a huge portion of the health care budget (e.g., about 25% of Medicare) on costs incurred during the year that people die.

What’s weird about this (and here I speculate irresponsibly) is that it's not obviously what most old people even want. Of course, most of us don’t want to die, but, given that we have no choice in the matter, I think we would prefer an end in which we accept death gracefully, feel sincere gratitude for the time we were given, and go gentle into that good night. (Bite me, Dylan Thomas.)

My feeling is that it is mostly the young who make this so very difficult. It is so hard to lose the people we love, and it hurts us to see once vital parents and grandparents just giving up the ghost. So, we insist that they fight and that the rest of the world fight for them, grasping at any straw the medical establishment has to offer. In this sense we are dealing with a problem of cooperation. It is easy for me to see how we are wasting money on useless interventions for old people. Just not the ones I care about.

I wish we had a system that would allow those close to death to transfer the money that would otherwise be spent attempting to prolong their own lives to the welfare of others who could really benefit from it. Childcare for a struggling single parent, or a home in a safer neighborhood, or an educational fund. That way people who are ready to pass on could make their deaths more meaningful and their acceptance of it as an occasion for sincere admiration rather than culpable capitulation. It would allow those of us who suspect we could have lived better to do something truly loving and helpful during our final days.

It wouldn’t fix anything, I know.

G. Randolph Mayes

Department of Philosophy

Sacramento State

My thanks to Steven D. Freer, M.D., for many illuminating conversations on this topic.