In his new book, Sick: The Untold Story of Americas Health Care Crisisand the People Who Pay the Price, Jonathan Cohn, a senior editor at the New Republic, offers a series of chilling anecdotes about ordinary Americans who lack affordable medical care. Theres the mother of three who, after her husband loses his high-tech job and family health benefits, puts off seeing a doctor and winds up dying of breast cancer. Theres the security guard in Los Angeles who cant afford treatment for his diabetes and winds up partially losing his vision. Theres the impecunious former nun hounded by bill collectors from a Catholic charity hospital. In all, Cohn fills eight chapters with similar tales of desperation, along the way pausing to provide policy analysis and historical backgroundall in an attempt to explain the larger forces at work in Americas health care crisis.
Cohn tells his stories with compassion and rich detail, vividly demonstrating how the cost of health care threatens not only the finances of ordinary Americans but, quite literally, their very survival. For those who want to know how Medicare, Medicaid, managed care, or medical savings accounts came to be, Cohn provides an easy-to-read primer. Though generally critical of market forces in medicine, Cohn is completely fair. He describes why it is actuarial logic, and not necessarily greed, that compels insurance companies to discriminate against people with preexisting conditions or to charge the old more than the young. Cohn doesnt demonize corporate medicine; instead, he dispassionately describes its limited ability, particularly in an era of vicious price competition, to pursue a social ethos while at the same time earning a return on capital.
Cohns book comes at a time when health care is once again rising to the top of the political agenda. Stung by the ever-rising cost of employer-provided health care, big business is at last beginning to put its weight behind health care reform. Wal-Marts CEO, Lee Scott, is now on record favoring universal coverage. In January, Americas Health Insurance Plans, a trade group of large insurers, rolled out a ten-year, $300 billion proposal to provide health insurance for all children and 95 percent of adults. Perhaps more important politically, the majority of Americans who have health insurance increasingly worry that theyll lose iteven as they resent having to pay an ever-rising share of its cost. All of the Democratic presidential candidates are vowing to achieve universal health care if elected. Some have very detailed plans. But unfortunately, the debate over health care continues to be poorly framed, and Cohns book, for all its virtues, is another example of that problem.
Like most critics of the medical care system in this country, Cohn begins from the premise that the fundamental problem with American health carewidely held to be the best in the worldis financial in nature: the system costs too much, and leaves too many people uninsured. But that is a flawed premise.
As a group, uninsured patients like those Cohn chronicles in his book face real hardships. But when they do receive medical carein emergency rooms, free clinics, community hospitals, and the likethey receive care that is as high or of higher quality as that of the insured.
Yes, you read that right. According to a recent RAND study published in the New England Journal of Medicine, uninsured patients receive only 53.7 percent of the care experts believe they should getthat is, appropriate, evidence-based treatment. But according to the same study, patients with private, fee-for-service insurance are even less likely to receive the proper care. Indeed, among Americans receiving acute care, those who lack insurance stand a slightly better chance of receiving proper treatment than patients covered by Medicaid, Medicare, or any form of private insurance.
How can this be? To answer that question, you need to understand what the insured are actually getting for their health care dollars. One answer: theres a lot of unnecessary treatment. Dr. Elliot S. Fisher, a Dartmouth Medical School researcher, estimates that 30 percent of all Medicare spending goes for unnecessary operations and procedures. For instance, under Medicare, the per capita cost of treating terminally ill patients in Miami is $50,000 more than the per capita cost of treating equally old terminal patients in Minneapolis, yet the patients in Miami dont live any longer. The explanation is simply that Miamis high concentration of specialists and hospitals is overtreating the citys patients.
To put a more human face on it, think of dying patients hooked up on ventilators, dialysis machines, and feeding tubes as an endless procession of specialists come and go, profiting from those patients prolonged and sometimes agonizing deaths. Some patients feebly resist these heroic treatments while their families insist on heeding Dr. So-and-Sos promises of a miracle cure. Other patients keep shopping for specialists until they find one willing to perform one last unnecessary surgery, such as a lung transplant for an eighty-five-year-old man already dying of liver failure. Yet whatever the dynamic among doctors, patients, and family, Fisher and others have shown that the presence of large numbers of specialists increases the chances of overtreatment with no measurable improvement in life expectancy or public health.
Another huge problem with prestigious institutions catering to the fully insured is their general lack of sensible preventative and follow-up care: for example, you might hope that after your high-priced cardiologist performs an unnecessary surgery he will at least follow up by letting you know the benefits of taking aspirin as a way of managing heart disease. Research has shown that for patients with stable angina (occasional chest pain and constriction arising from chronic heart disease), for example, taking a daily low dose of aspirin reduces the chances of adverse cardiovascular events by 33 percent. But Fisher found that in Americas highest-spending hospitals, only 74.8 percent of heart attack victims receive aspirin upon discharge from the hospital, as opposed to 83.5 percent in lower-budget competitors. This may be one reason why survival rates for heart attack victims are actually higher in low-spending hospitals than in high-spending hospitals.
Whats more, these spendthrift hospitals often skip other routine preventative care such as flu vaccines, Pap smears, and mammograms. This general lack of attention to prevention and follow-up care in high-spending hospitals helps to explain why not only heart attack victims but also patients suffering from colon cancer and hip fractures stand a better chance of living longer if they stay away from elite hospitals and choose a lower-cost provider instead. Given this reality, it is perhaps not surprising that patient satisfaction also declines as a hospitals spending per patient rises.
What explains these findings? Remember first what American doctors and hospitals get paid to do. Outside the Veterans Administration and a few staffmodel HMOs, they dont get paid to keep and make patients well. They get paid to provide treatmentsand thats a big difference. It means that most American doctors and hospitals have no economic interest in your long-term well-being, while they also have an enormous economic incentive to perform operations and procedures for which Medicare and private insurance pay well. The result is a systematic bias toward the overtreatment of patientsand particularly of those who are well insuredand a simultaneous neglect of prevention and well-being.
The effects of these skewed incentives are particularly bad at hospitals in which patients see lots of different specialists. Not only does the presence of each additional specialist increase a patients chances of overtreatment by that specialist, it also increases the chances of the patients being harmed by a lack of coordination or effective disease management. Each specialist is responsible for this or that body organ, and nobody is in charge of the whole patient, much less for the overall quality of care.
The problem of poor coordination could easily be rectified by a greater use of electronic medical records. But again, outside the VA and a few very large HMOs that enjoy long-term relationships with their patients, no business case exists for making the necessary investment in information technology. Precisely to the extent that such an investment succeeds in improving patient outcomes, it also reduces providers revenue. As the health care economist J. D. Kleinke has observed, this is the dirtiest of American medicines many dirty secrets: Bad quality is good for business. And the surest road to bad quality is bad or no information.
In addition to overtreatment and undertreatment, there is also flat-out mistreatment. Consider the following statistics: The Institute of Medicine estimates that lack of health insurance among people aged twenty-five to sixty-four causes 18,000 premature deaths annually, which is appalling. But the Institute of Medicine also estimates that up to 98,000 Americans are killed in hospitals every year by medical errors. In 2006, the IOM issued a new study that found that hospital patients in the United States experience an average of at least one medication error, such as receiving the wrong drug or the wrong dosage, every day they stay in the hospital.
All told, according to the RAND study, Americans receive appropriate care from their doctors only about half of the time, and the results are deadly. In addition to the 98,000 killed by medical errors, another 126,000 die from their doctors failure to observe evidence-based protocols for just four common conditions: hypertension, heart attacks, pneumonia, and colorectal cancer.
American medicine is not only mismanaged in practice, its also stunningly uninformed by basic scientific evidence about which treatments work better than others and about which in fact do harm. For example, Cohn opens his book with a story about a woman who dies of a heart attack purportedly because she did not receive a cardiac catheterization, a procedure in which a cardiologist inserts a balloon into a patients circulatory system and then expands it in order to open a partially blocked vessel. The moral of the Cohns story is unclear to me, but Cohn seems to believe that if more patients had access to cardiac catheterization this would reduce the rate of heart attacks.Yet a study in the Journal of the American Heart Association last year revealed that while the elective use of such procedures has been skyrocketing over the last ten to fifteen years, there has been no change in the rate of heart attacks. Since Cohns book went to press, a new blockbuster study sponsored by the VA and published in the New England Journal of Medicine has similarly found that the specific use of angioplasties (the opening of a blocked blood vessel using a thin tube with a balloon or another device on the end) and stents (the tubes that prop open a blood vessel) is no better at preventing heart attacks than nonsurgical therapeutic treatments, such as taking aspirin or cholesterol-reducing drugs.
Indeed, the current understanding of what causes heart attacks calls into question why these procedures even could prevent one. As David Waters, chief of cardiology at San Francisco General Hospital and professor of medicine at the University of California, San Francisco, points out, most heart attacks are not caused by narrowed arteries, as the old clogged pump model used to suggest. Instead they are caused when plaque, a deposit of fatty material in an artery, breaks off and forms a clot that abruptly stops blood flow to the heart. At that pointbut not beforecatheterization becomes appropriate. Underscoring the dangers involved in this form of overtreatment, about 1 in 100 people undergoing a catheterization procedure for diagnostic purposes die during it or while in postoperative care.
Cohn also tells the sad tale of a hardworking, loving husband suffering from heart disease, diabetes, and other ailments who purportedly died because of cutbacks in Tennessees Medicaid program. The cutbacks, Cohn tells us, forced the man to give up some of the state-of-the-art prescription drugs [that] had not only kept him going but also alleviated his suffering. Specifically, he was supposed to be taking more than two dozen separate medications, the majority of them prescriptions. They were enough to fill a Jack Daniels whisky glass every morning, afternoon, and evening.
I dont know what those two dozen drugs were, nor how many different doctors may have prescribed them without each others knowledge. But on its face this story certainly suggests that the man may well have been among the 1.4 million Americans injured every year by harmful drug combinations and other medication errors. And then, too, there is the not unlikely possibility that the pile of pills in his whisky glass included the then-state-of-the-art anti-inflammatory drug Vioxx, which, according the Food and Drug Administration, has sent more Americans to the grave than were killed during the entire Vietnam War.
Here is another example of how the current debate over health care reform is misframed: to most of us, including Cohn, it seems self-evident that the lives of the uninsured would be improved if they had access to CAT scans, MRIs, and other high-tech imaging devices found in Americas best hospitalsand in some cases they would. But as health policy writer Shannon Brownlee shows in a forthcoming book, Overtreated: Why Too Much Medicine Is Making Americans Sicker and Poorer, autopsy studies consistently demonstrate that doctors are only slightly less likely to make misdiagnoses today than they were in the 1930slong before the invention of MRIs and CAT scans. Its not just that these imaging devices too often produce false negatives; its also that they often produce false positives, which lead to unnecessary and often dangerous treatment. Thanks to high-tech imaging, America is now experiencing an epidemic of pseudo-disease, as doctors submit patients to debilitating surgery and chemotherapy for tumors so small and slow growing that they present no danger of causing death or even any symptoms.
And despite what you may have heard on Oprah or the Today Show, there are also no studies demonstrating the value of the latest fad in imaging technology, Cardiac Computed Tomography Angiography, or CTAs. These machines expose patients to up to 400 times the radiation dose of one chest X-ray, according to a recent article in Health Affairs, but no one can show what benefit they offerexcept money-making potential for entrepreneurial health care providers and doctors practicing defensive medicine. Experts who study the health care outcomes across populations consider no technology as notorious for its overuse and lack of cost-effectiveness as imaging.
Cohns book will show youin heart-wrenching detailhow under our current system of private insurance too many people cant get the coverage they need at a reasonable price. I applaud him for his hard work and skill. But is this the disease that afflicts the U.S. health care system, or just one of its more awful and unacceptable symptoms? Cohn seems to think its the disease, and prescribes as a cure making everyone eligible for Medicare. But the majority of researchers who study the actual processes and outcomes of American medicine think the lack of affordable insurance is but a symptom of the larger ailment. Treating symptoms often makes sense, and we should treat this one. But that doesnt get us to a cure.
The key to the cure is understanding that there is more than enough money already sloshing around the health care system to ensure every American access to quality care. Unfortunately, the current practice of American medicine, whether financed by Medicare, insurance companies, or other sources, is stunningly inefficient, unsafe, unscientific, and getting worse. And thats why it costs so bloody much.
Americans spend more per person on health care than residents of any other country, and they have very little to show for it except more medical bills and too many ineffective, and even harmful, treatments. Americans, for example, pay twice as much per person as Britons for health care. Yet even though the British are more prone to drink heavily and are just as likely to smoke as Americans are, they live longer and are far healthier.
This is true even among privileged members of both nations. For example, a study published in the Journal of the American Medical Association in 2006 found that the prevalence of diabetes among American college graduates aged fifty-five to sixty-four is 9.5 percent, compared with 6.1 percent among British college graduates of the same age. Even after one controls for the fact that Americans of all classes are more prone to obesity, the disparity remains, with Americans of all classes more likely than their counterparts in Great Britain to suffer from diabetes, heart disease, and cancer.
Similar health disparities exist between Americans and the citizens of all other advanced nations. Why? You dont have to travel to some far-off foreign country like Sweden, or even to Canada, to find the answer. Nor do you have to rely on mere econometric speculations. The cure to Americas health care crisis is a system thats already up and running right here in the United States, with facilities in every state, plus the District of Columbia and Puerto Rico. It is, in fact, the largest integrated health care system in the United States, and it points the way to the future.
Most of its doctors have faculty appointments with academic hospitalsover the years, two have won the Nobel Prize for medicine. The systems innovations have included the development of the first artificial kidney, the cardiac pacemaker, the first successful liver transplant, and the nicotine patch, plus many advanced prosthetic devices, including hydraulic knees and robotic arms.
More impressively, health care quality experts also hail it for its exceptional safety record, its use of evidence-based medicine, its health-promotion and wellness programs, and its unparalleled adoption of electronic medical records and other information technologies. Finally, and most astoundingly, its the only health care provider in the United States whose cost per patient has been holding steady in recent years, even as its quality performance is making it the benchmark of the entire health care sector.
Though comparatively few Americans, especially among coastal elites, have any contact with this system these days, and even fewer qualify for its services, its example shows that it is possible to make vast improvements in the quality, safety, and effectiveness of the health care all Americans receive, and to do so for a fraction of what an unreformed health care system would cost.
Im talking about the Veterans Administration, which over the course of the last decade or so has undergone a remarkable transformation. Even with its problems, the VAs model of care turns out, in study after study, to be the best the American health care system has to offer. As Harvards John F. Kennedy School of Government gushed, in awarding the VA a top prize in 2006 for innovation in government: While the costs of health care continue to soar for most Americans, the VA is reducing costs, reducing errors, and becoming the model for what modern health care management and delivery should look like.
This is another inconvenient fact absent from the health care debate. What can you say about it? The VA is an example of the government running a health care system, not just writing checks to cover other peoples medical bills, which is all that Medicare does. The VA also has a near-lifetime relationship with its patients and therefore has an incentive to invest in prevention, disease management, and protocols of care that demonstrably workincentives that are weak or absent throughout the rest of Americas fragmented health care system. Medicare for everyone, or some similar scheme for universal coverage, just doesnt address the root cause of Americas health care crisis, which is poor-quality, uncoordinated care. The VA model of health care does.
Yes, I know there was a scandal at Walter Reed Army Medical Center. But Walter Reed is an Army facility and not part of the Veterans Administration system. Yes, I know there is an emerging consensus that the Bush administration and the Republican Congress did not provide the VA with enough money to cope with some forms of care needed by some returning veteransnotably mental health services. But this problem, like most of the others at the VA, have to do with access, not with the quality of care received by those who get in.
Upon hearing some anecdote about the VA, we should always ask, Compared to what? As a system, the VA outperforms the rest of the health care sector by every conceivable metric, including wait times and, of course, protection from catastrophic medical bills. And it is more cost-effective: for every patient who switched from Medicare to the VA, the taxpayers would save about one-half to two-thirds in medical costs, while the patients themselves would receive demonstrably higher-quality care. Step one on the road to true health reform should be to allow all veterans on Medicare to use their entitlement for VA care, and then gradually expand access to the VA model of care for all Americans.
Adopting the VA model, with its salaried doctors and its extensive use of electronic information technology and evidence-based medicine, would cure the American health care crisis. Throwing more money into the current, fragmented, profit-driven system without changing the actual practice of American medicine might ease the problems of the uninsured temporarily, but would also give us more inappropriate, sometimes dangerous, and ever-more-expensive care.
Its important to remind Americans, as Cohn does admirably, that our current method of financing health care puts them at grave and growing financial and medical risk if they lack insurance. But what is ultimately the greatest threat to the publics purse and the publics health, while also ultimately the best argument for a universal, government-controlled health care system, isnt the problem of the uninsured. Its the problem of every American who wants to stay or get well.
Phillip Longman, a Schwartz senior fellow at the New America Foundation, is author of Best Care Anywhere: Why VA Health Care Is Better Than Yours, published in April by Polipont Press.