Saturday, November 28, 2009

Lipstick on a pig

I’ve had spirited conversations lately with friends, both in person and online, about current attempts by Congress to reform the healthcare system. Some believe anything our elected officials touch becomes corrupted and that political paralysis is thus a good thing, while others are pulling for a full government takeover.

In the world of realpolitik, we’ll likely end up with a “reform” package that ultimately does little to contain the ruinous escalation of costs. That day comes later, after we as a nation finally acknowledge the necessity to ration care. The notion that any country can provide an abundance of health services for all its citizens without bankrupting itself is an illusion. Consider the impact of aging baby boomers or the predicted doubling of the incidence of diabetes in the next 15 years if you think we have any hope of getting through this without fundamental change.

The problem is that by historical standards, Americans in the 21st century are a remarkable healthy people. Good health, it happens, raises expectations for still better health, and that in turn requires improved technology. The healthcare industry generates through its success its own market. It is profitable not simply because people are willing to pay for it, but also because it allows them to have an increasingly long life in which to desire more of it. The healthcare industry feeds off public desire and demand.

Public disclosure: My family and I live a relatively affluent lifestyle because of my participation in this racket. As editor of a newsmagazine for 20 years that catered to radiologists and related paraprofessionals, I benefited economically from the enormous expansion of medical technology that occurred through the ‘80s and ‘90s. Millions of dollars of ad pages showed up between the covers of Diagnostic Imaging because we provided a congenial editorial environment for the companies that made CT scanners, ultrasound scanners, and an array of other high-tech imaging devices.

As I learned during those years, technological medicine is a dream-come-true in a culture that chooses to ignore limits. The expanding domain of what constitutes health is no less important a force in working against healthcare cost containment. Areas that would once have been handled by the criminal law or the social welfare system, such as substance abuse, have been brought under our definition of health. Most everyone with health insurance has provision of some level of mental health coverage, which is a good thing if the current healthcare debate is driving you crazy.

So we are left today with trying to change the mechanics of our healthcare system without examining the psychological, moral and political assumptions that lie below it. As John McCain might have said, it's like putting lipstick on a pig. We simply can’t control costs, preserve choice, constantly enhance quality and avoid government interference and regulation—all at the same time. Yet that’s the bill of goods that Congressional Democrats are peddling. They're not attempting to restrain demand, but want to stimulate more.

The single thread that binds together all those countries that spend less on healthcare than the U.S. but achieve equally good or better health outcomes is their willingness to accept regulation, and to live by it as a daily constraint. Because there is no intrinsic limit to our perceived health needs nor the progression of technological medicine, if there are to be limits, they will need to be imposed by political force—just as we are about to see with universal coverage. There does not appear to be any other sufficiently strong incentive to slow consumption of healthcare. As I learned personally in my little corner of the medical world, radiologists and the companies that provide them with their tools can always make the case for some new application for MRI, or any other medical imaging device.

For there to be serious cost containment, a change more radical than cheap political tricks is needed. The hard philosophical truth is that, despite what Americans tend to think about themselves, we bear the disquieting burden of mortality. Illness, decline, aging, and death can only be forestalled and never permanently vanquished. This burden works against those who would have us believe that we can maintain choice in our healthcare while controlling costs. As we’ve gotten better at controlling or curing disease that were relatively easy to understand—infectious diseases like smallpox, tuberculosis and even HIV/AIDS—we’re left with those that are more complex and intractable—like cancer. People used to die quickly. Today we die more slowly, and expensively.

This is the discussion that’s yet to come. How do we confront our physical decline and death, when the overwhelming momentum of our healthcare system is directed toward denying both? There can be no serious cost containment until we accept limits on our mortality, and make political peace with that reality. I’m confident we’ll eventually reach our financial limits and begin to reign in costs because if there’s anything we as a culture love more than our good health it’s our money.

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