There are two forces at work in the system of health care
delivery in the US which are essentially incompatible. One, which might be
called the “health” approach, is focused on improving the health of the people.
This could, should, and does include efforts to control costs, because this
makes it possible to maximize the number of people who can benefit. This
approach, which is codified in almost all international and most national
health goals, seeks to use whatever resources exist (financial, structural,
institutional, and human) to have the greatest health benefit for the most
people. The World Health Organization (WHO) defines health as “…a state of complete physical, mental and
social well-being and not merely the absence of disease or infirmity”. A
cornerstone of this is understanding that public health measures, which
benefits populations, are generally of greater urgency and wider benefit than
individual medical interventions.
While the need for a public health approach is perhaps more
obvious for poor countries which lack, for example, clean water, it is no less
important for wealthy nations such as the US; we just don’t usually think of
the fact that we usually have clean water as a “health benefit”. As with many
things, we are less likely to notice things that are good than those that are
problems, and we relegate them to the background of our consciousness. We don’t
wake up each morning saying “I’m glad I don’t have cholera because I have
access to clean water!” Indeed, it is only when we travel abroad and have to
use only bottled water, or when a crisis like the lead pollution of the water
supply in Flint, MI grabs our attention, that we give this any thought at all.
The result is that public health efforts pay the price; less than 6% of our US
health expenditures are on public health, with the bulk spent on direct
individual medical care, and the profit that insurers, providers and middlemen
skim. In addition, our country spends much less, proportionally, on efforts
that impact upon the social determinants of health, those characteristics of people’s
lives (housing, food, safety, education) that affect people’s lives much more
than health care.
Still, when we – or those we love – are sick and in need of
medical care we are grateful that it is there. But for many or most of us, it
is often hard to pay for it. When we cannot, when the incredible amount of
money we have to pay for medical care (often even when we are insured)
threatens our families’ well-being, our ability to pay for shelter, food,
education, it is a different story. And we know that access to and use of such
individual medical care is neither randomly distributed among the American
people nor allocated based on the greatest need; no one is shocked to discover
that rich people get more medical services. (What may be shocking to learn, however,
is that this does not always lead to better health. Services are often delivered
-- to those who can pay -- whether they are really necessary or not, and
sometimes this leads to complications and worse health!)
It is in this context
that a new study in the journal Health
Affairs by Dickman, et al., “Health spending
for low-, middle-, and high-income Americans, 1963–2012”[1]
is very revealing. The authors provide data on both the amount health spending
among the American people over that 50 years, and how it has been distributed
by quintiles of income. To summarize the findings: in 1963, before Medicare and
Medicaid, spending was heavily skewed toward wealthier populations, but after
those programs were implemented spending became more equal among the quintiles
(although, adjusted for disease burden, which is higher in low-income
populations, it was still not equitable). Then, over the last decade studied,
the spending gaps returned, with much more being spent on the upper than lower
quintiles (despite the generally better hea
The reason for this is the prominence of the second force at
work in health care systems (you were wondering if I would ever get to this!),
which I will call the “profit” approach. This approach looks at health care as
a commodity to be purchased and marketed. Unsurprisingly, those taking this
approach choose to preferentially market both certain services over others (those
for which the reimbursement is much higher than the cost of providing them,
called even in non-profit institutions the “profit margin”), and market them to
certain populations over others (those with money or insurance, and relatively
good health so there are less likely to be costly complications). While this
approach tends to favor the wealthy, leading to the data presented by Dickman
et al., it also favors the less sick. Since older people tend to be sicker than
younger (and are covered by Medicare, which pays less well than private
insurance), this may in part explain why the quintile-of-income differences are
less for the elderly. In summary, health care providers (mainly hospitals and
physicians, but also others), want to market the services on which they can
make the most money to the people who, arguably, need them the least. You can
have greater difficulty accessing care because you are the wrong person (too
poor, too sick) or have the wrong condition (one for which treatment has a low
profit margin).
Dickman and colleagues present their data fairly
dispassionately, without hammering home the obvious conclusion that it reflects
a society more driven by the “profit” than the “health” approach to health care
delivery. Essentially, it is a story of half-hearted (called “practical” by its
advocates) efforts to introduce greater equity into our health care system being
overcome by the tactics that smart and well-paid insurers and providers employ
to “game the system”. In his regularly outstanding “Quote of the Day”
commentary on the Dickman article, titled “Redistribution
of health care from the poor to the wealthy”, Dr. Don McCanne takes the
discussion a little farther, noting that a single-payer health care system, in
which everyone had the same coverage and which could regulate the marketplace,
decreasing the profit incentive, would improve the population’s health.
When I wrote to Dr. McCanne that the effort to find ways to
preferentially deliver high-profit care to well-insured high-income folks
rather than those who needed it most upset me (OK, I said it made me want to
puke), he wisely responded that it “seems
like our health care system has excelled at creating ‘work arounds’ for those
measures that health care justice advocates keep attempting to advance.”
Usually when people use the term “work arounds” they are referring to finding
ways to do what needs to be done in the face of bureaucracy or inefficiency. In
this case, however, it means propagating inequity in order to make money.
The two different approaches, putting “health” or “profit”
as the primary impetus to our health care system, get different results.
Personally, I favor “health”. Sadly, though, the other is often more prominent.
[1] Dickman
SL, Woolhandler S, Bor J, McCormick D, Bor DH, Himmelstein DU, “Health Spending
For Low-, Middle-, And High-Income Americans, 1963–2012”, Health Affairs 35(7):1189
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