By David Brown
Sunday, January 11, 2009
Over the next few months, this country will engage in the first serious national discussion on health care in 15 years. Most of the talk will be about ways to make medical insurance available to all U.S. citizens. There will be a fair amount, too, about the need to make the hodgepodge "system" of American health care safer, better and more efficient. What we're unlikely to hear, though, is something like this:
Arresting the growth of health care spending in the United States is impossible. The policies and programs we're suggesting will either accelerate the upward trend or slow it temporarily, but they won't stop it. Health care costs will go up year by year until you die, and probably until your children die, too.
This difficult truth, which has emerged over the past half-century, is leading the United States and the rest of the industrialized world into a new era of humankind.
We are on a collision course between our wish to live longer, healthier lives and our capacity to pay for that wish. Whether we can somehow avoid the collision is perhaps the most important domestic issue of this century. From now on, health care costs will be up there with globalization, terrorism and climate change as a force shaping our world.
For most of recorded history, food production was the chief goal of human labor. In the United States, that time is long gone. We spend a little less than 10 percent of our income on food, down from 25 percent in 1930. We spend twice as much -- 21 percent -- on shelter. But health care -- that's where we really get our wallets out.
Last year, 16 percent of the nation's gross domestic product went for health care, about $7,600 per person. In terms of human effort, health care is the new food. By 2016, when it reaches 20 percent of GDP, it will be the new shelter. If it grows at its present rate through the first three-quarters of this century, it will consume 38 percent of GDP by 2075. It will then be the new food and shelter.
This isn't a mistake. If it were, we might have a chance of stopping it. It's success -- the way things are supposed to be, and the way we want them to be.
"At the end of the day, when it comes to controlling health care costs, the enemy is us," said Drew Altman, head of the Henry J. Kaiser Family Foundation. "Americans want the latest and best in health care technology, and we want it down the street, and we want it now."
Medicine lies at the intersection of two profound forces. One is the desire to survive, which motivates all living things. The other is the ability to make things, which distinguishes humans from other animals.
Crowding that intersection are thousands of opportunities for avoiding or curing an illness, feeling better, living longer and being happier than our grandparents ever could have imagined. These opportunities take the form of implantable defibrillators, replacement knees, periodic colonoscopies, weight-loss surgery, life-long antidepressants, anti-retroviral medicines, breast tumor gene scans, biologically targeted chemotherapy, heart-lung transplants and prenatal tests for dozens of dread diseases.
These are just a few of the fruits of our desire to survive and our capacity to create -- and there's lots, lots more right around the corner.
All these things, of course, haven't come for free. Health care spending has grown faster than the economy, by an average of 2 to 3 percent a year, at least since the end of World War II. In the first five years of this decade, it averaged 6.9 percent a year.
Medicare, the federal government's insurance program for the elderly and disabled, provides an especially dramatic snapshot of health care's growing claim on our wealth and labor. In 1970, Medicare was 0.7 percent of GDP -- 70 cents of every $100 the country produced. By 2005, it was 2.7 percent. Last year, it was 3.2 percent, according to the Medicare trustees' annual report. In 2082, the program is projected to be 10.8 percent of GDP. Over the past half-century, total federal income tax receipts have averaged 11 percent of GDP per year. So unless something changes, in about 75 years, Medicare alone will cost as much as the sum of all our federal income taxes.
This kind of growth doesn't come just from jacked-up prices, a bureaucratic and inefficient delivery system or increasing numbers of sick and old people. Something else has to be going on to explain such steady, predictable, relentless growth.
That something is innovation. Various health economists have estimated that somewhere between 40 and more than 65 percent of the growth in per capita health care spending since 1940 can be attributed to advances in medical care. Each year, there's more that can be done and more that's judged worth doing.
And the effect has been profound. Consider heart disease, the leading cause of death in the United States. From 1980 to 2000, deaths from heart disease fell 40 percent. If the 1980 death rate from heart attacks had held in 2000, about 342,000 more Americans would have died in that year alone. A team of researchers recently calculated that 47 percent of those lives were saved by better medical care -- involving such developments as clot-dissolving drugs, coronary stents and medicines to prevent congestive heart failure. About 44 percent were saved because people had reduced their risk factors -- quit smoking, lowered their cholesterol and gotten their blood pressure under control, with many of those improvements also the effect of better drugs and medical care.
Two years ago, another group of researchers, led by Harvard economist David M. Cutler, looked at the money spent on health care from 1960 to 2000 and asked the crucial question: What did it get us? Their answer: Plenty -- but improvements are costing more all the time.
Their study found that over those 40 years, the life expectancy of people of all ages had increased. Not surprisingly, investments in the health of children were more cost-effective than investments in 60-year-olds. What's more interesting is that extending life cost more as the 20th century progressed, even taking inflation into account. In the 1970s, it took $46,870 to add a year to the life expectancy of 65-year-olds. By the 1990s, it cost $145,000.
As we become healthier, it takes more effort to extend our lives than it did in a time when we were less healthy (and dying prematurely). Fifty years ago, American medicine picked the low-hanging fruit of life-extension as clean water, vaccines, antibiotics, insulin and other cheap innovations became available to everyone. Now, we're going after the higher and more expensive stuff.
Take implantable cardioverter-defibrillators, or ICDs. These "ambulances in the chest" shock hearts out of the fatal rhythms that are a major hazard for people who survive large heart attacks. Vice President Cheney has one wired into his heart.
Three years ago, a team of researchers calculated that putting an ICD into a heart-attack survivor added one to three years to the person's life expectancy. The cost? Between $30,000 and $70,000 for every year of life gained. In the world of "cost-effectiveness analysis," that's judged to be worth it, the convention being that a treatment that buys an extra year of life for $50,000 or less is "affordable."
Medicare estimates that about 500,000 Americans now qualify for an ICD on medical grounds. Undreamed of when our parents and grandparents were having heart attacks, these devices are keeping or will keep thousands alive. Sowho's going to give one up in the interest of slowing the growth of health care spending? Not I. And I suspect not you, either.
Of course, there are ways to save money.
Administrative costs consume 24 percent of health care spending, according to one often-quoted estimate. Establishing a more unified health care system could probably cut that in half. There is also tremendous regional variation in medical care in the United States, so bringing everybody into line will reduce costs.
Then there's prevention, a favorite money-saving ace in the hole. The trouble is that prevention also costs money. A study that got front-page coverage nationwide in the week after the election not only demonstrates that but also shows how much we value small improvements in health. A group of researchers in Boston found that if you prescribe cholesterol-lowering drugs to people whose cholesterol levels are normal but who have evidence of mild body-wide inflammation, you can reduce their chances of developing cardiovascular disease by about half. "It's a breakthrough study," effused the head of cardiology at the Cleveland Clinic. "These are findings that are really going to impact the practice of cardiology in this country," said the head of the National Heart, Lung and Blood Institute at the National Institutes of Health.
What few stories pointed out was how little bang you actually get for this prevention buck. You have to treat 95 people for two years to prevent one "event" -- death, heart attack, stroke. At a cost of up to $1,200 a year for the drug, Crestor, that's a big investment to make year after year to help a few people. Given the response to the study, however, I suspect it's an investment we'll soon start making routinely.
Furthermore, there's little evidence that preventing disease reduces health care costs over the long run, although it obviously extends lives and prevents misery.
So what's likely to happen?
Over the short term, many experts say, there will be the sort of adjustments that humans make whenever necessities -- food, heat, shelter -- become scarce. We'll pay more for health care. We'll give up small things in favor of it. We'll cut corners. We'll complain. And then we'll find other corners to cut and reluctantly pay still more. Of course, the "we" may not include all of us; some Americans pay little or nothing for their health care. But as a society, we'll all pay more.
In the longer term, however, not just the United States but the entire industrialized world is facing a conundrum resembling a famous one of 200 years ago. In 1798, an English parson named Thomas Malthus published "An Essay on the Principle of Population as It Affects the Future Improvement of Society." He laid out a chilling scenario in which population growth outstrips food production and produces a cycle of famine, catastrophic population decline, recovery, famine and catastrophic decline, over and over.
This was the so-called Malthusian Spectre. It was a hugely influential -- and horribly frightening -- idea. It kept members of Parliament awake at night. But it never came to pass because of two as-yet-undiscovered truths that Malthus never imagined.
The first was that scientific agriculture would eventually double, triple and quintuple crop yields. The second was that when industrialization pulled huge numbers of people out of poverty, infant mortality fell, women became more educated, and the value of their labor rose. The net result was a huge decline in birth rates. This is known as the "demographic transition," and virtually every region of the planet has gone through it.
We will need something like the revolution of scientific agriculture and the demographic transition to rescue us from the Malthusian Spectre of health care spending.
What it might be -- ah, that's what nobody knows.
David Brown is a medical doctor and a health and science reporter for The Washington Post.