With Congress debating ways to reform health care throughout the United States, editorialists railing for or against a single-payer system, and my wife today attending a 4-hour lecture on billing at the hospital where she will be working in a week, my thoughts have been on health care costs. I think there is no question that our current system has gross inefficiencies, with gigantic bureaucracies built up to determine what has been done, what it should cost, who should pay for it, etc. Removing the middleman of private insurers could certainly be worth some significant savings, but turning things over to government generally means more infrastructure, not less. That is a debate I will leave (for now) to those wiser and more knowledgeable than I.
What I would like to discuss today may be an even more controversial position: that what we need is less health care. I do not recall ever hearing anyone else espouse this opinion, but it seems quite logical to me. If we think about it, the relationship between resources spent on health care and the results we get from it (average life expectancy, quality of life, whatever metric you prefer) is a sigmoid function of the type shown below. There is a minimum result level that we will attain even if none of our resources are spent on health care. The results rapidly increase as we allocate a moderate amount of resources toward them, then continue to grow very slowly as more and more resources are used.
Because we value human life and health so highly, it is natural to find ourselves on the asymptote of this curve, doing whatever we can to get the best possible results. If this is the case, then perhaps we could reduce expenditures by 30% and lose only 5% in quality. It may seem that no price should be too high to take care of the health of our citizens, but a simple thought experiment will demonstrate that this is not the case. Suppose that a single person had a very rare disease. A guaranteed cure for this disease is known, but a single dose of it can only be manufactured by the combined labor of 100 people for a year and the destruction of 1000 acres of rainforest in raw materials. No one, except perhaps our unfortunate victim, would advocate this as reasonable.
Knowing where to draw the line is of course quite tricky. It is easy to decide that some treatment is not cost-effective when none of our loved ones are in need of it, but another thing entirely when this is not the case. If we were to do something like this an impartial, evidence-based commission would need to make the decisions. I would guess, however, that the easiest thing to justify axing would be treatments that have been well-studied, are known in the average case to only increase life expectancy by a few months, and require an enormous expenditure per patient.
I am not, of course, proposing that such care should be outlawed, simply that it should not be considered a public good in a possible nationalized system. When insurers refuse to cover the least cost-effective treatments it causes outrage, and perhaps it should if people have been paying premiums under the belief that they will in return be given the best care money can buy. But that assumption must be changed; we could easily, if we valued it highly enough, spend our entire GDP on health care. There comes a point, however, where allocating resources elsewhere would result in a much higher increase in quality of life for society at large.
Perhaps my feelings on this stem from my own preferences. I have health insurance, but not the sort that would help me out in the event of a very serious illness. I want to be taken care of if I have a broken bone, a staphylococcus infection, arthritis, etc. If I were diagnosed with something that is likely to kill me within a few months if left untreated or a few years if I undergo a treatment regimen that will keep me in the hospital and sickly most of the time, I would choose the former in a second. Perhaps I would feel differently if I had children I wanted to see grow up, but my life has been full enough that at this point I feel no need to grasp for more, however unpleasant it might be.
It’s not obvious to me that the slope would be increasing for the lower values of money spent. Any reason for choosing this curve rather than, say, an inverted decaying exponential?
I agree that our society generally overvalues after-the-fact health care (surgery, medication etc.). Ironically, we hugely undervalue preventative healthcare.
The healthcare industry is enormous and contributes nothing directly to a country’s production. It only contributes indirectly by keeping people alive so they can work longer. From a purely economic perspective, you could do a simple evaluation. A procedure is worthwhile only if it’s cost is at least offset by the patient’s expected increase in production. I think if you actually did this analysis you’d find that a lot of procedures, especially for elderly patients, are not worth the cost economically.
Of course, you can easily argue that there is more to contributing to society than increasing industrial production. I believe artists are extremely important to society, but provide no production. Scientists, entertainers, teachers, lawyers and many others fall under this umbrella as well. Also, I believe the elderly have an inherent value to society because of their wisdom and extensive life experiences. There is at least one group of people that take up a significant amount of healthcare resources and do not contribute to society in any way: those suffering from severe dementia. I don’t feel awkward saying this because I have personal experience with a person with Alzheimer’s. My grandmother, who I was close to when I was young, had severe dementia for the last five to eight years of her life. The person I knew ceased to exist when I was a teenager, but her body did not expire until years later. She had no recollection of her family and needed assistance with basic tasks. Was it morally acceptable for the state to pay for my grandmother’s care with money forcibly taken out of other citizens’ pockets?
Comment by Michaluk — June 20, 2009 @ 10:23 pm
Michaluk: Actually, that makes a lot more sense, given that values of x < 0 are nonsensical. I was looking for a function with a horizontal asymptote and took the first that I could find.
Comment by chadhogg — June 20, 2009 @ 11:02 pm
Interesting points although I think Ryan makes another good point about after the fact health care. I wonder if it would decrease overall health care costs and improve people’s health and life expediency by simply focusing upon prevention. Such as making not a doctor but somebody trained both as a nutritionist and a personal trainer the primary care provider and requiring the patient to see them lets say monthly to every other month. But then again I am sure if such a program were seriously proposed some people would be up in arms claiming that it is a civil rights violation but if one is honest something like this would be the ultimate health care system if one was really concerned about the health of the people’s bodies and not the overall profits of the medical industry which profits from people’s sickness not health.
Comment by John Grebe — June 21, 2009 @ 6:26 pm