The U.S. Health Care system is like the Titanic — a big, fancy,
expensive ship that unequally doles out limited resources depending on class
status and is destined to hit an iceberg and sink.
A professor used this analogy recently to provoke students to look
more deeply into the complex and intractable factors that determine health status. Biology
and genetics surely are important, he said, but one cannot ignore the environmental,
social and economic factors that influence an individual’s
susceptibility to disease.
Comparing the U.S. health care system to the Titanic is an analogy as hackneyed as saying the system is in crisis. Yet, it remains useful.
An estimated 1,500 people aboard the Titanic’s maiden voyage died
when the ship struck an iceberg. The greatest, most advanced cruise ship
of the time lacked sufficient lifeboat space, and as a result, the total death rate was very high
— about two-thirds of all passengers died.
But an analysis of death rates by steerage class shows that
first-class passengers were twice as likely to survive as third-class
passengers. And among women, who were much more likely to survive than
men regardless of class, only 3 percent of first-class women died compared with 51 percent of third-class women.
Class, wealth and gender affected passengers’ ability to secure one
of the limited lifeboat spots, and ultimately, determined whether they
lived or died. Just like on the Titanic, income and class, which correlate to education level, remain the greatest
determinants of health in the U.S. and most other nations.
While decades (perhaps centuries) of research shows that health status is determined primarily by "upstream" factors, much of the current health policy discussions focus on matters "downstream," such as insurance status, patient safety, the quality and cost-effectiveness of care, and reducing costs. (Admittedly, insurance status and income are strongly related, but research controlling for access to care, shows the poor still have worse health outcomes.)
The health policy discussion has a slightly different tone in Britain, where the highly regarded Acheson report heavily influences the debate. The 1998 report proposed 39 interventions to improve population health, especially among the disadvantaged, and only three were based on traditional medical care. The authors believed that addressing poverty, employment, education, housing and environmental issues would most significantly improve the public’s health.
Is the current U.S. health policy focus lop-sided, giving too much attention to health system issues, when, in effect, improving education and reducing income inequality would lead to much greater improvements on the population’s health?That’s a tricky question because teasing out causes and the order of determinants is difficult. The current health policy discussions should do a better job of acknowledging that good health is not independent of having a good job, feeling financially secure, getting a good education and the overall feeling that you’re making progress toward a better future for your family. But policies to improve the quality and value in the health system and contain rising health costs are inextricably linked to achieving the former.
Rapidly expanding Medicaid budgets, for example, have forced most states to cut back on education, particularly subsidies to higher education. This has led to significant tuition increases for the three-quarters of students who attend public colleges and universities, and possibly, a decline in quality of those institutions.
The Medicare Part D expansion is another example of the trade-offs between health access and income. As economist Victor Fuchs noted, covering more drugs for seniors is paid for in part by reductions in Social Security. Consequently, the elderly may be entitled to expensive medical care but unable to afford other basic necessities.
The U.S. health care system is often cited as the most technologically advanced in the world when it comes to medical treatment, but just like the Titanic passengers’ fates were determined before they stepped on the boat, our life expectancies depend mostly on what happens before we ever enter a hospital.
Health policy interventions that improve quality and reduce wasteful spending to secure greater value in the system, however, could reduce pressure on other budgetary areas, which are being crowded out by increases in direct health spending but may have equal or greater impact on health status, such as education, safety-net food programs, housing, etc.
Reducing per capita health spending is necessary to focus on more upstream interventions. Achieving spending reductions is a goal without a clear path, but maybe the Titanic offers one more lesson: Surely, it would have been prudent to forgo a few expensive chandeliers in order to have sufficient lifeboats, giving everyone on board an equal opportunity for survival.
I’m just saying we need to be careful what we wish for.
The housing thing is mostly about who gets to eat all the bad paper and how big the ultimate taxpayer bill will be. It’s not like the assets have disappeared. $300 billion of bad mortgages against $100 trillion in assets (US economy’s asset base) does not a depression make. The mortgages end up getting settled at 80 cents on the dollar, not liquidated.
I don’t think we’re even going to get a recession, just a scary slowdown. This boat has no captains. . .
tcoyote. I dunno, we may get the “wish” of the depression as apparently the “regulators” of the housing loan markets in the last few years have been “asleep at the wheel” Titianic captains leading us into the oncoming iceberg of a housing collapse. We’re certainly taking on water pretty fast.
Somewhere Kate and Leo are bravely trying to make their escape…
As with limited life boats on the Titanic, it seems Scott Shreeve in his column on concierge medicine wants us to believe that more class separation will bring better healthcare. Is this yet another trickle down economic solution?
It is inexcusable that there is as much income inequality as there is in our health system- both for patients and providers. There’s serious inequity inside the care system- hence the 10X disparity between the family practitioners and the specialty surgeons, dermatologists or interventional cardiologists. There is less, but not zero, income inequality and class disparities in health outcomes in most “national” health systems, just not as bad as in ours.
But unlike the Titanic, it isn’t the people in steerage who get the worst care. They have Medicaid, and a more comprehensive benefit package than many privately insured people have today. It is the uncovered working class, the young and people in late life transition that get shafted in our current system.
It’s also worth noting that the “rich”, the lifeboat people, aren’t getting a very good product either. It’s still unreliable enough that they need to take guides with them with when they get hospitalized to avoid getting shafted. It’s not clear how much better having fifteen doctors and a medicine cabinet full of meds is for you than having none.
I’m not sure overblown, melodramatic metaphors like this get us anywhere.
People seem almost to be hoping we hit an iceberg, like people hoping for a real Depression so we can restore the New Deal.