Wednesday, December 13, 2006

U.S. Healthcare is broken

You've no doubt heard the title statement before. U.S. health care is indeed broken. We spend more of our GDP on health care than any other country in the world, but our outcomes are not superior. Our outcomes are not even as good as those of many other countries. Much internationally- cited medical research takes place on American soil, with American minds and American money. Nobel prize winners are disproportionately American - at least in the sciences. Individuals desiring advanced education travel from all over the world to our universities.

Yet we are the only industrialized nation without national health insurance. (South Africa lacks it, but apparently not everyone considers it "industrialized.") Some developing nations, and virtually all "first-world" nations provide better health care than the United States does to its citizens. With 40 million people lacking health insurance, and health care expenses the predominant cause of personal bankruptcy, plainly something is wrong here.

Pharmaceutical and medical device companies, insurers and the top-paid physicians (not all of them) are profiting from a system that is partly private, profit-driven and partly publicly-funded. The private interests don't want to give up their stake to an entirely public system in which they would cease to exist or make much less money, but the public system as configured now can't go on not benefitting from the lower-risk, lower-cost pool of insureds who are taking part in the private system. Those in the public system are the high-utilizers: the debilitated, the chronically severely ill. This pool of health care consumer is tremendously costly to care for, and the private system stays ahead by maintaining the prerogative to simply dump these people onto the public sysem when they become too costly to insure. Our system is largely tax-dollar funded, make no mistake: 60% of American health care is paid for in the public system through Medicare and Medicaid. Virtually all residents of long-term care facilities, for example, are cared for in the public system.
This intricate power tapestry has to be unraveled. A single, shared system, not a hybrid of public and private interests has to prevail if any semblance of justice is to be achieved.

Costly and innovative new therapies are developed and brought into medical usage without accounting for the costs. It is simply assumed that a $40,000/year cancer drug is worth the cost. People receive bone marrow transplants and then are pushed onto a system that lacks the resources to provide sufficient followup care. Insurance pays for three home health nurse visits regardless of the real needs of the older adult who has had a hip replacement. Fabulous new diagnostic imaging systems costing many millions are assumed to be worthwhile in the absence of evidence for them. Invasive procedures do not have to be shown cost-effective, merely safe for human use, before they are adopted into medical practice. In fact, there is no governing body for medical procedures at all, as the FDA governs drug approval. And no one pays attention to costs but the insurers and, of course, the patient who files for bankruptcy because his retirement fund was not large enough to cover a catastropic illness. This situation permits medical values (which are far from sinister, but biased nonetheless) to drive medical expenditures.

We need to reconsider our objectives and this will require a hard look at the values that drive health care. Medicine values life. Physicians are socialized to view death as failure, as the enemy. If a chemo drug doesn't stop a patient's cancer in its tracks, they say "the patient failed chemo." They "battle" disease. This "war on disease" mentality lacks perspective. Everyone will die. The discipline of medicine has succeeded (with help from personal hygiene, public sanitation and so forth) in extending lifespan considerably. Thanks to medicine, very few women now die in childbirth, which two centuries ago was a huge cause of premature mortality.

Our expanded lifepsan, however, has had consequences. It made senile dementia, cancer and heart disease part of our everyday lives. These are not diseases prevalent in societies where people died before 40 years of age. These are aging-related diseases. So now we need to deal with these diseases, and they are much more complex than the ones medical science solved in past centuries. They cannot be wiped out by a course of antibiotics. It's not by neglect that we haven't discovered "the cure" for cancer. It's because there is no one cure. This pathological process is tremendously complex; as soon as we've cut off one head, it sprouts another. We now have longer lifespans that are still lengthening, and older people who develop diseases that put huge demands on the health care system, leading to ever-increasing costs because we have not had the guts to draw the line somewhere, fearing it will be arbitrary wherever it is drawn.

We have to embrace realistic values that value human life but recognize limits, and then we have to draw that uncomortable line.

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