Healthcare Myths

However, I return to this subject, putting fear and trembling aside, because it is a hugely important policy tangle and even a modest pull at the ends of this Gordian knot is worth some considerable effort. It is also a particularly apt subject for the exercise of one of the dedicatory principles of this site, the uncovering of things people know, that ain’t so. As in so many areas of policy, false assurance aided by ideological blinders, is more damaging to rational problem-solving than ignorance.

So let us begin with a post that will do no more than ask one very basic question. What is the relationship between healthcare and health? This is a rather sweeping place to start; but it is the best possible way of setting this table. I rely on American data here; but who pays the piper is not relevant to this macro-question. The economist Robin Hanson has written that:

Let’s chew on this for a bit. We are talking about as much as $5 trillion per year spent in the U.S. alone, a sum so immense that the government’s share of this burden is crowding other public goods off the table, leaving nothing but allocations for debt service and pensions and crumbs for such minor concerns as education.

So, we spend trillions on illness alleviation, which, damn important as it is when you are the one ill, has a rather tenuous connection in statistical terms, to population health. Would we make this choice if more of us really understood what it means in terms of other opportunities foregone — that is a fascinating question. Of course, one reason we seem price-blind in this area is that virtually all of us expect to be sick at some point, and we want that state-of-the art system ready and waiting, like a Rolls Royce idling in the driveway that most of us won’t take on the road until we are very elderly drivers.

Perhaps another reason we just don’t see the disproportion here is that, if we did, we would have to broaden the debate beyond what I will now call illness care, and examine uncomfortable lifestyle issues. Hey, looky, looky, all around, we’re getting fatter. We are giving ourselves metabolic diseases in record-breaking numbers. According to Dr. Robert Lustig and his team in California, metabolic disease has now passed infectious disease as the leading killer world-wide – the main villain, the “toxic western diet.” Metabolic diseases are in the main, diseases of lifestyle choice; which is another way of saying diseases we could opt not to get. (Lustig is a determinist on this point; but I disagree with him on that stance.)

Perhaps, we would be more reflective, if we knew more about the positive dangers inherent in overuse of the system. The CDC estimates that, again in the U.S., 1.7 million people a year, or close to 10 percent of everyone who goes to a hospital catch a nosocomial, or hospital-acquired infection, leading to 100,000 deaths per year. A significant percentage of those people should, in a properly articulated system, never have gone to a hospital in the first place.

Perhaps a psychologist of the stature of Carl Jung could contribute a different thesis as to why so much rational cost/benefit analysis seems to bounce off ‘the system’ like small ordinance off a drug lord’s limo. Is there any doubt that we have fetishized ‘the system’, made of it a talisman with which to ward off and postpone unto the most advanced possible dotage, that fear of all fears that coils and uncoils in our unconscious — the spectre of death itself? I do believe CGJ might have said something close to just that, and that is particularly bad news for the rational problem solvers among us.(If this speculation seems a little well, metaphysical for your taste; consider how much healthcare money we choose to spend on ourselves and/or our loved ones in the last year of life!)

Finally of course, health care policy is a particularly convenient flail for the Left and the Right to beat each other over the head. On the left, ‘only a government run system can allocate resources with fairness for all’. On the Right, ‘taking consumer choice out of the system is morally objectionable and probably unconstitutional; and removing competition guarantees massive inefficiencies and uncontrollable cost escalation.’ We all know the dialectical drill. I have said before that un-reflective partisanship characterizes healthcare policy debate perhaps more than it does any other area of social policy controversy.

Well, well, it would seem that irony is everywhere in this healthcare world, and we may now know a little more about why rational discussion of the system is so difficult. It is not a health care system, it is a sickness alleviation and death prevention system. Things need to be properly named if they are to be properly addressed. It sucks resources like no other public good ever has in peacetime. It is so complex, it is fair to say that no one understands it. It is a uniquely seductive arena for ideological (magical) thinking. And yeah, do we ever hate the thought we are all going to die. Let us put no limit on what we will spend to keep breathing for an extra six-months when we are ninety-four..

I would love to hear your thoughts as comments on the site. How would you reallocate the spending pie?

Note: For those who want more validation concerning the iffy relationship between health and illness care, please reference the now famous (infamous in some circles) RAND Health Insurance Experiment and the more recent Oregon Medicaid study.