Sunday, June 23, 2019

The high cost of US Healthcare: It's not mostly the demanding patients!

Did you know that American healthcare is the most expensive in the world? And did you know that health outcomes here are way lower than in other developed countries? Well, since you’re reading this blog, you probably did. But here’s a scoop: one of the main reasons for this high cost is apparently the demanding nature of American patients!

Wow, you’re thinking! I was under the impression that it was greedy drug manufacturers who sell drugs in the US at many times the price they are available in other countries! And insurance companies, making huge profits by collecting high premiums, co-pays, and deductibles and then trying their best to not pay for care! And the health industry itself, providers like hospitals and health systems, who, even when ostensibly “non-profit” act like for-profits trying to make the most money possible and paying their executives in the millions (although maybe less than the C-suites of the drug and insurance companies). You probably thought it was the whole corrupt end-stage gangster capitalist system that never met a dollar it didn’t want, no matter who it hurts.

Well, sorry you’re so naïve! Just read this article by David H. Freedman in the July, 2019 Atlantic, The Worst Patients in the World”. The reason health care in the US is so expensive is the fault of people like his 74-year old father: “An accomplished scientist who was sharp as a tack right to the end, my father had nothing but disdain for the entire U.S. health-care system, which he believed piled on tests and treatments intended to benefit its bottom line rather than his health.”
And yet, Freedman points out, he demanded tests when he was sick! And he not only did nothing medical to try to help his health (like going to get checkups or preventive care), he actively undermined it by
…practically using the list of prohibited foods as a menu. He chain-smoked cigars (for good measure, he inhaled rather than puffed). He took his pills if and when he felt like it. By his late 60s, he’d been rewarded with an impressive rack of life-threatening ailments, including failing kidneys, emphysema, severe arrhythmia, and a series of chronic infections. Various high-tech feats by some of Boston’s best hospitals nevertheless kept him alive to the age of 76.
He also punched a doctor.

Then Freedman goes on to argue that it is both these characteristics, abusing oneself and not taking care of one’s health, including eschewing tests that were “intended to benefit its bottom line rather than his health,” but then demanding that the medical care system provide all the most expensive possible of those tests once he was sick, that typify the behavior and approach of many Americans and account for, in large part, the high costs of health care. While Freedman acknowledges his agreement with the concept of Medicare for All, he suggests that “We ought to consider the possibility that if we exported Americans to those other countries, their systems might end up with our costs and outcomes.”

Wow again! If w. imported US people (“patients” is the medical term for people) to, say, Canada or the UK or Denmark or France, their healthcare costs and outcomes might be, respectively, as high and poor as ours. It is not the first time that this argument has been made, but it is being featured in a major magazine, and written by a presumed progressive (or at least supporter of Medicare for All). Maybe it is worthy of being considered!

Or rejected. Maybe it is a fallacy to presume that it is a flaw in the character of the people who live in the US, compared with those in other countries, that is responsible for the high cost and poor outcomes of our health care system. Or maybe not, considering everything else about us (which I will not now consider in depth), our collective national character illustrated by things like putting migrant children in cages, denying global warming and the climate crisis, supporting the fossil fuel industry with far more money than we spend on education, or maintaining a ubiquitous system of racist law enforcement and imprisonment, just to name a few. I think it is a fallacy, though. I am sure there is a wide range of personality types within the US as well as in other countries; people who are more or less hostile, people who are more or less demanding, people who are more or less suspicious of anything that smacks of authority, and people who are more or less willing to do what they themselves can do to help themselves. So why does it seem like there are so many more in the US, and that this is a major contributor to our health care costs?

Because it does seem as if there are. I have been a doctor for a lot of years, and I have seen lots of people who do little or nothing that should be in their own control to improve their health, and yet are very demanding of expensive resources being used not only when they get sick, but after there is little chance of it benefiting them. People who, like Freedman’s father, contrary to all that “should” happen, are kept alive many years after they “should” have died as a result of the bad genes, habits, environmental factors, and luck that led them to the diseases they had. Yup. Bad behaviors. Shame! And then wanting “everything done” when it is too late, and, oh yeah, you don’t have to pay – the insurance pays. Which raises everyone’s rates. Yup, selfish.

But why would Americans be so selfish, mean, demanding? Why would they be different from other people? Would, in fact, exporting Americans to other countries raise their costs and worsen their health outcomes? That’s not an experiment that we can do easily, although there is no evidence anecdotally of this occurring. The real issue is the one I talked about at the start of this piece: a health system designed to enhance profit for the companies who own it (and the pieces of it). It is their practices that encourage many of the sorts of behaviors that Freedman and others note.

The entire health system is built on high-cost, high-tech interventions. There is far less profit in controlling, say, diabetes, with cheap generic drugs than in the newest high-cost patented drugs. There is enormous emphasis on procedures, diagnostic and therapeutic, that have little evidence of benefit, or evidence of benefit in a very narrowly-defined population. It is absolutely NOT true that a screening test of benefit for a high-risk population, for example, is of benefit for lower-risk people. There is incredible expenditure at the end of life, when often all that can be done is prolonging suffering. It is done because people, and companies, make money on it. And to complain that people behaving relatively rationally in response to these incentives is the problem is to engage, as is all too common, in victim blaming.

And if we blame the victims, we are hardest on those who are victimized in the most ways. The poor, the uneducated, the jobless, the homeless, the imprisoned, the children. Those who “demand” care because, historically, they are members of a class, race, or group that was systematically denied it. You may not feel a lot of sympathy for Freedman’s father (or maybe you do) since he had so much – a scientist, presumably with a reasonable income – who took poor care of himself and then cost the system piles of money to keep him alive until 76. But the system is hardest on those with the least.

And that is why “compromise” solutions to increase health care access rather than make it universal are not only morally wrong but bound to fail. The biggest question about “Medicare for All” is how much it will cost. But the answer is that the cost will be made up for by eliminating exorbitant private-sector profits. Half-measures, “Medicare for More” or “Improved ACA” don’t do that.

Everybody in, nobody out!

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