The following essay appeared on the website of the Hastings Center, which is running a colloquium on the values behind health care reform.
“One could make a good case that improvements in education and job creation could be a better use of limited funds than better medical care.” – Daniel Callahan, “Medical Progress: Unintended Consequences”
The president emeritus of the Hastings Center opens his insightful essay with the observation that the American people’s faith in medical progress is boundless. In this short comment, I want to expand on his thoughts by reexamining the cardinal tenets of that faith, since they embody a set of values that distract us from building a society that promotes good health, an infinitely more difficult task than building a better sick care system.
What are the core values driving our belief in high-tech medicine?
At their root, they are the values of good old-fashioned American individualism. This is the land of opportunity, where everyone has the God-given right to thrive and prosper. It’s also the land of the second chance, a place for the self-made and remade man – like President Ronald Reagan or Don Draper of the award-winning new drama “Mad Men.”
Death in this value system is not the end of a journey, but a rotten break. It’s the end of our chance to make a mark in the world, thus a fate to be avoided at all cost. Ray Kurzweil, the nonpareil Baby Boomer inventor, is the faith’s high priest, gobbling dozens of pills and supplements daily in his quest to remain on his “Fantastic Voyage: Live Long Enough to Live Forever,” to use the title of his 2005 book.
These values have been written into the laws that govern the delivery of health care, especially Medicare. That universal, single-payer system was designed to provide health care for our oldest and therefore most vulnerable citizens. But in setting up that system, Congress said the government (i.e., all of us) would pay for any medical intervention deemed “reasonable and necessary” to return a person to health, and it could never consider cost when making those determinations. How deeply ingrained are those values? So deeply ingrained that it was child’s play this past summer for right wing demagogues to stir up passionate outrage over nonexistent efforts to “pull the plug on grandma.”
The public religiously believes there will be a technological fix for the hundreds of diseases that may hit us as our bodies degenerate, and tithes accordingly. Any effort to limit prices for what must be paid for new technologies is met with cries from industry that it will stifle innovation. The taxpayers provide the seed corn for new technology by investing nearly $30 billion a year in basic research through the National Institutes of Health and other government health-related programs (this year supplemented with $10 billion in stimulus act funds).
But that’s just the start of the process. Those researchers are encouraged to patent their findings and start companies to bring their inventions to market, a reflection of another core American value – entrepreneurialism. The government refuses to limit prices so these companies will have “incentives” to leap the regulatory barriers to entry. And even when it invests in comparative effectiveness research to determine if these new inventions are any better than older interventions, the government will insist that those findings cannot be used to determine payment policy.
Where has this lead us? We have new anti-cancer drugs that cost $50,000 to $100,000 a year despite extending life a matter of weeks or months. We are helping pay to develop cameras-in-a-pill that can scope out our innards, the latest twist in imaging technology. We will collectively pay additional billions for a pill that can be taken once a day instead of twice a day. As I write, a hospital in suburban Chicago is building a $130 million cyclotron to deliver proton beam therapy to prostate cancer patients in the name of sparing them the life-altering side effects of incontinence and impotence that affects some patients given traditional interventions like surgery or radiation. Does it work any better? No one knows. Did these men need these interventions in the first place? For many, the answer is no. Will anyone tell them the alternatives, or challenge the erection of this new altar to high-tech medicine? Alas, the answer is no.
The results are as described by Callahan and others: half of the annual increase in the cost of our increasingly unaffordable health care system can be attributed to the proliferation of newer and always more expensive forms of care. What gets lost in that lament is that the return on this investment is on a downward spiral. Our life expectancy not only lags behind other advanced industrial countries, but every year it grows a little more slowly.
Why has our technological faith failed us? The answer is simple. Increased longevity has nothing to do with extending the natural human lifespan. Societies increase longevity by eliminating premature mortality. Technology is one means to that end, but it is probably the least efficient method. It’s definitely the most expensive.
The dramatic increases in longevity we saw in the early 20th century was largely the result of better sanitation that reduced infectious disease deaths. The gains of the postwar era were largely the result of better housing, better heating, less burdensome work, and more leisure – each a product of an increasingly wealthier society. In more recent years, cleaner air, less smoking, and better diets have played a bigger role than medical interventions in extending life.
That’s not to say that medical technology hasn’t helped. It can and does save lives. It can even perform miracles in some cases. But the truth is that investment in technology will never bring the U.S. up to the longevity standards of other advanced industrial countries. Why? Because our misplaced faith has distracted us from tackling the real and enduring determinants of ill-health in our society- poverty, income inequality, social insecurity, and status anxiety, the hallmarks of our increasingly dysfunctional social order. There’s a vast literature on the social determinants of health. Alas, it has gone unnoticed and unremarked in the current health care reform debate.
Rebuild our health care delivery and health insurance systems? It’s a necessary, even laudable goal. But it’s not sufficient if we want to improve our population’s health. Until our values allow us to put that goal to front and center, we’ll be forever doomed to disappointment by the poor returns from our massive investment in high-tech medicine.