While many Americans are unaware of it, every country in the world is now struggling, like the United States, to control health care costs. The most striking part of that struggle is that other nations all have that problem regardless of how they are organized. They are beset with three basic underlying drivers of modern health care: aging populations, great but often expensive medical technologies and high patient expectations. Most of the other countries do better than the United States in containing costs in great part because they maintain universal health care systems. But the United States does not have that advantage, and the net result is that it has the most costly system per capita of any other in the world and politically the most troubled.
The non-partisan Congressional Budget Office is charged with laying out plausible short-term and long-term cost scenarios for health care. These are dire and get worse with each future decade. What the C.B.O. cannot do, however, is make political predictions, but now that President Obama has been re-elected we can at least be confident that the implementation of the Affordable Care Act (A.C.A.) will continue.
During the campaign neither candidate wanted to directly confront the cost problem of American health care, particularly Medicare’s rising expense. The reason is not hard to uncover, that of the considerable resistance of the elderly—close to 80 percent in the polls—to any significant change in that program. For years the C.B.O. has been saying the same thing: Medicare costs can only be controlled by significantly raising taxes or cutting benefits or some combination of the two, but the electorate does not care for either option, alone or in combination.
The difficulty is that to have a significant impact tax increases aimed at supporting Medicare would have to be applied not just to rich Americans, but to the middle class as well. Increasing out-of-pocket costs should help bridge health care deficits, but under with the present program the average Medicare beneficiary already pays from $3,000-$5000 out-of-pocket each year; some can pay as much as $10,000. Keeping in mind the financial security of the elderly, intertwined with the Medicare coverage, it is not clear how much higher can out-of-pocket charges can be raised.
While the Social Security program is in fairly good shape for the foreseeable future, it will not cover by far the income needs of most beneficiaries (and was never intended to do so); And 75 percent of those over 65 in 2010 were retiring with only $30,000 in personal retirement funds. Some of that small savings must of course pay for the Medicare out-of-pocket costs.Controlling Costs
In short, aside from the most affluent, there are certain to be great financial burdens on the elderly in the future, well beyond those they already endure with the present Medicare and Social Security programs. How are we even to imagine benefit cuts in that context? Nothing but pain is in store for us and even more for those nearing 65 but not yet there. The A.C.A. will cut costs to a considerable extent over the next decade, particularly because its Independent Payment Advisory Board will be able to enforce automatic cuts in the Medicare program if expenses are not controlled. But beyond that kind of brute financial force most of the A.C.A. cost cutting provisions are speculative in their actual impact and even more so over a 20-30 year period. Wisconsin Congressman (and recent vice presidential candidate) Paul Ryan’s proposal remains the most plausible to come from the Republican Party. It gradually shifts more and more of the economic burden on the elderly themselves.
Far more difficult to comprehend is the nature of the cost problem itself, and I want to distinguish between a managerial and a philosophical belief. The managerial belief, by far the most commonly embraced, is that better organization and management can solve it. Our health care system is, among other things, inefficient and wasteful, makes poor use of scientific evidence in patient treatment, offers the wrong kind of financial incentives for physicians and hospitals and is altogether too expensive. But all that can be reformed—or so the argument goes.
But at a deeper level, the problem is also that of the philosophical model and vision of medicine that the health care system is based on—and it is at bottom the reason every country, not just the United States, is struggling. It is the progress- and innovation-driven model. It has made death the ultimate enemy and is dedicated to a utopian vision of medical progress that neither recognizes nor accepts any inherent limits. That is not a vision that can be coped with by better management. It is not our health care failures that are the ultimate problem. The trouble lies with it very success.
To make that view comprehensible, it may be useful to look at some basic data, to examine the leading causes of high costs, and at the place of chronic illness and death in health care. I will focus on Medicare. In 2010 it covered 40 million people over 65, with a projection of 88 million by 2050. The fastest growing U.S. age group are those over 85. Why is there a problem? The three basic cost drivers all come into play in the high cost of caring for the chronically ill, mainly the elderly suffering from hypertension, heart disease, diabetes, cancer and Alzheimer’s disease.
The top 1 percent of such patients account for somewhat more than 20 percent of spending ($275 billion in 2009), and the top 5 percent almost half of the spending ($623 billion). The bottom 50 percent cost only $236 per capita; the top 5 percent $41,000; and the top 1 percent $90,000 per capita. It is the success of keeping sick people alive much longer than in the past that is at once a great medical triumph and the source of the health care system’s greatest economic stress. An important part of that problem is costly end-of life-care, not just the few days or weeks while patients are obviously dying but the often longer preceding time when it is not certain whether a person is dying or not, when they are vigorously treated with the hope that they are not at death's door.Tough Prognosis
Here are what I think of as hard medical facts, but ones that hardly anyone wants to accept because they call into question some fundamental values of the modern medical enterprise. Three of them stand out:
Medical research, much cherished, sometimes helps to lower costs but in the aggregate over the years it has increased them. It has done so not by curing the major chronic diseases, which it has failed to do, but by its capacity to keep people with them expensively alive for a longer period of time.
Cures and prevention can have wonderful benefits for individuals but the cure of one disease simply means they will die of another. It is what I call the longitudinal costs that matter for society, the total accumulated costs of each illness incurred over a lifetime. A person’s life can be saved from heart disease at 65, from cancer at 75, a repairable stroke at 80 and they will survive to get Alzheimer’s at 85. There is a bill for each successive victory over death. We can all think of friends or relatives who have spent their last years in and out of I.C.U.s.
Technological innovations usually yield marginal benefits only but often at a high cost. The emergence in recent years of exceedingly expensive cancer drugs—from $50,000 to a whopping $320,000—that yield only a few additional weeks of survival stand out as startling examples of expensive innovations, not to mention the many less expensive but costly innovations that, taken as a whole, make I.C.U. care so costly. The latter can be called the high altar of innovation, where belief in progress is most pronounced and most costly.
Just as false hope feeds a good share of the costs of chronic illness, so also it feeds a belief in organizational miracles. In the end it is not just the health care system that needs reform, but the way we think about medicine itself. An open-ended belief in progress and innovation led us into the chronic illness morass, and no way out is at present visible. The great biologist Rene Dubos many years ago wrote a book with the prophetic title The Mirage of Health. Illness, decline and death are an intrinsic part of our human nature, never to be overcome, he argued. After years of rising, average life expectancy shows signs of leveling off. Nature may well be reminding us now to take Dubos’s analysis more seriously than we have.
A reform of medicine will require a number of steps. Above all it will necessitate a rethinking of medical progress, one that works with finite, affordable goals. The most important goal would be to accept death in old age, to realize that a boundless fight against it may satisfy many of us personally but be financially harmful to us as a community; and in any case extended chronic illness in our last years under the present regime is too often more a burden then a blessing.
The place I would draw the line is 80, not a hard and fast line, but one that should lead us to a shift in perspective. Once one reaches that age, most people have lived full lives and have had the opportunity to enjoy most if not necessarily all of life’s benefits. I am now 82 and, while I hope my family and friends will be sorry to lose me when I die, I cannot imagine that I will be an irreparable loss to our common good. Others will take my place. I flatly oppose euthanasia and physician-assisted suicide, but I do not consider it an inherent evil that we all get old and die, nor do I believe that Christianity does. It is not an insult to our human dignity that our lives are finite. I do not believe in a level playing field for each age group. Children should have the highest priority, the working adult cohort responsible for running the society and raising the children should come next. The elderly, like myself, should come last. I have six children and five grandchildren, and I worry about a health care system for the elderly that shuts its eyes to the burden on younger people.
Many may find this way of thinking altogether unacceptable. They believe that it is simply immoral to use cost as a sometimes necessary standard for setting health care priorities or that such an accounting reflects ageism at its worst. I believe that society has an obligation to help young people to become old people, but it cannot exhaust public resources to help old people become older indefinitely, nor can it be indifferent to the burden on younger people whose payroll taxes pay for health care for the elderly.
I have an organizational plan to go with the reformed medicine I have in mind. Picture a pyramid. At the bottom would be public health, the next level would be primary and emergency medical care. Above that would be routine hospital care. The next level would be advanced hospital care, including ICU care for those with a good prognosis. At the very top would be the expensive high-technology procedures, and particularly their use with those over 80 with a borderline or poor prognosis for a much longer life thereafter. The aim of the health care system would thus be to make the lower levels affordable and accessible to all, but increasingly curtailed at the highest levels, pushing everything down the pyramid as far as possible.
The elderly would not, under this plan, be neglected. They would require and still receive good primary care, economic sustenance, available and subsidized support from family members or others and the building of aging and assisted living communities integrated into the life of younger people. Cure has been in the medical saddle too long and has lost its way. It should now be better balanced with care. We need, that is, not just better management of health care, but a fundamental change in the goals of medicine and the way we think about aging.