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Sunday, November 24, 2013

When Will Health Care Ever Cost Less?

The answer is, when you reduce the amount and degree of care provided. It's an answer nobody wants to hear but it's true.

On this year's Veteran's Day, a talk show on NPR mentioned the treatment of war-caused PTSD in veterans. A caller asked why PTSD is so common among veterans of modern wars but was not nearly as common back in WWII or before. The experts and/or insiders of course corrected them that back then the same post-combat neuroses was not diagnosed as PTSD but rather was called other names, such as shell shock. Most of the sufferers were not treated, because the medical community didn't know how. So many of them treated themselves with alcohol and psychoactive drugs, and died premature deaths.

Fifteen years ago when I was in school, managed care and preventive care was all the rage. The argument was that if you give people health care before they get very sick, they would live longer and healthier lives, and the cost of health care for a population would go down or at least not continue to go up. The reality of the next decade and half has proved them wrong.

The logical flaw in the managed care premise is obvious: If people live longer and healthier, they would only get sick later, but they would get sick and eventually die anyway. Why would they need less health care in totality?

One might argue that if a person lives longer and healthier and delays the inevitable aging and illness leading to death, he could work longer and produce more in his life. I would argue, however, that the longer he works, the more disposable income he has to spend on treating his illness and delaying his death. How would that reduce the cost of health care?

Spend some time with old people and it will become abundantly clear. The demand for health care is a bottomless pit, because the thirst for life and fear of death is boundless. It is usually limited only by what medical science and technology can offer at the time. Before an elixir is invented to extend people's lifespan to 70 years, people did not spend money on it and died at 69. After the elixir is invented people spend their money to buy another year of life. The same can be said for any other treatment. Before there was penicillin, where would people with infection spend their money on? Before there was methotrexate and paclitaxel, where would people with cancer spend their money on? Not on health care. Once the treatments become available, how can you not spend money on them?

Very occasionally, spending money on one treatment can save you money on alternative treatments. For example, spending on Prozac has saved a lot of cost on psychotherapy. But such cases of saving are uncommon. Most of time, medical advances are like urban sprawl --- build it and people will come. As long as you have a few more years of life or less pain to sell, people will buy it, if they can afford it.

Built on good intentions, the third-party payers of health care only make the cost balloon. Socially it is a sensible philosophy to want to give most people access to most life prolongation technologies. Psychologically, it removes the financial measurement out of individual person's calculation. How much are you willing to pay to prolong your life for another month? If you have a billion dollars, you may be willing to pay a few hundred million. If you have a hundred dollars, you may be willing to pay fifty, saving the rest for a last meal. If you have none and need your parents or children to cough up their life savings, you might spend nothing and choose to give up the last month of your life.

However, once this contemplation is taken out of individual's consideration and put in the hands of an insurance company or the national payer, I bet everyone feels the urge to want to spend "as much as possible" to prolong one's life. It's no longer your own money you spend on the care you need and want. Everyone wants the longest life money can buy.

If I were to devise a system that can truly stem the escalating cost of health care, I would use the collective money pool (as all medical insurance, be it public or private) to take care a set of treatments that have a finite amount of cost. Beyond that, you or your guardians decide how much you want to spend to prolong your life. If you get pneumonia, the system pays for your antibiotic treatment. If your pneumonia turns into sepsis and spending a hundred thousand dollars may save your life, you or your family will have to decide if you can and want to spend the money on that. Such a system assumes that life has a price. Above that price, the system will not pay for life.

This proposal sounds horrible, I know. Life has a price. Shudder. It also highlights the gross inequality between people --- If you have more money, you can afford to live longer. If you don't, you get the basic but less care and therefore shorter life, most likely. However, in another sense, the system is quite equal. It assumes that, to the system, a rich man's life is worth the same as a poor man's. The system spends the same amount on each person. And, because this system does not endlessly escalate, it is able to sustain itself and ensures the largest number of people get at least basic care. The rest is left to the random draw of luck, be it your wealth or your genes, and your own choice.

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