Once upon a time, when a man felt unwell or was injured, someone fetched the doctor. The doctor might not have done much for his patient except explain symptoms and urge endurance, but the interaction eased the patient’s worry. He paid the doctor in money, or maybe chickens, and very often got better because the body is good at fixing itself. With time doctors gained more knowledge and tools. More treatments became possible. Along came offices and hospitals and then insurance against the unexpected costs of hospitalization.
The birth of health insurance
After WWII, when wages were frozen, employers attracted workers by offering “hospitalization insurance” as part of an employment package. No one foresaw the chains that came to bind patients to employers and doctors to insurance companies, because no one foresaw the explosion of technology that drove a perpetual escalation of costs. That awaited another well-intentioned idea – a government sponsored system to pay for the health needs of the elderly (Medicare), and later the poor (Medicaid). The infusion of federal money (also known as someone else’s money) into health care spurred medical advances and hospital care in ways never seen before. Sensing unlimited growth potential, big business came calling and dragged the entire enterprise onto Madison Avenue, labeling it “health care.” Hospitalization insurance morphed into the medium of transaction for all services rendered.
Out of control
If, in this new medical world, you feel like a faceless passenger on a runaway train, you are not alone. And if you seek out the locomotive, you will find that there is no engineer – just a bunch of firemen madly shoveling coal into the engine. The firemen are your friends and neighbors. They work for insurance companies, pharmaceutical and medical device companies, advertising agencies, the media, and the government and, of course, universities, hospitals and clinics. The health care industry is a giant machine employing millions of people and consuming close to 20% of the gross national product. (Note: the original version of this column was written in the 90s, when the figure was 12%; when it was published in early 2008, the number was 15%). Changing direction is no simple matter, but staying the current course seems foolhardy.
The power of invisibility
We fear the costs of health care, we resent the power of insurance companies, and we are submerged under a tidal wave of scare tactics designed to sell products we don’t understand and have no way to evaluate. We lack physicians who know us well, and we use emergency rooms and urgent care facilities as family doctors. Unless we are seeking “non-essential” care, like cosmetic surgery, the transaction of worth in medical encounter – the bill – is mysterious, hidden under an economic invisibility cloak that rivals Harry Potter’s. While we all know and weigh the costs of life’s other “essentials” such as food and shelter, we are not allowed to make value judgments about medical interventions that grow more numerous by the year.
Invisibility of cost interferes with responsibility on the part of doctor and patient alike in judging the worth of these interventions. The impulse to “just check things out” is much easier to indulge when little or no money changes hands. When “insurance pays,” doctors feel fewer qualms about ordering expensive tests, and no urgency about understanding and explaining the arcane statistics behind the studies that prompt the treatment fashions of the day. Ever-present fear-mongering sells us on the need for diagnostic tests and interventions to treat “risk factors” and patients feel guilty if they have the temerity to question recommendations for life-long drug taking and repetitive screening tests and X-ray exposure. And in the meantime, medical costs have risen to levels that bear no relationship to the costs of the rest of life, the arcane language of medicine is so rarefied that the non-medical “consumer” has no hope of understanding it and must rely on interpretations by the “purveyor,” and all too many of the purveyors have only a rudimentary understanding of the products they pitch.
What is the goal of all the money spent?
As long as we hide costs in the accounting books of insurance companies, we can fritter away one political season after another pretending the “healthcare problem” is just about access to medical care. We can avoid the tough questions about the goals of health care. Do we want to tie up the bulk of our resources in the last 6 months of life (as happens in Medicare spending), or can we acknowledge that intense intervention at the end of life adds a great deal of distress without any gain? How much do we waste and how much anxiety do we cause with extra tests and rules aimed at keeping lawyers at bay? As we now begin to watch upcoming generations fail to exceed or even meet the life expectancy of their elders, can we admit that the high tech medical road we’ve chosen may be the wrong one? That real prevention is better than treatment? That real prevention requires education, patience, consistency and self-discipline more than obsessive searching for disease already present? That cures of disease come from full understanding of the science involved, not from premature attempts to sell the products of research to as many people as possible?
As you negotiate the jungle of media hype and medical sales pitches, you must resist being manipulated by fear, and regain the trust in your body. It is not a fragile edifice that will crumble without constant examination and intervention. It is a marvel of engineering that attempts to protect you from what you do to it. It will never be free of minor, self limiting ailments, but it responds well to good care that befits its design for life 40,000 years ago. Be glad modern medicine is there for the catastrophes that cut young life short, and to help with cataracts and hearing aids and artificial joints. Be relentless in questioning of the need for drugs and procedures, and ask what will happen if you opt not to go ahead. Don’t be steamrolled by statistics – ask for absolute numbers rather than percentages, which tend to make results look more impressive than they actually are. For instance, 50% reduction may mean that only 1 person instead of 2 out of a thousand died of a given disease after the new treatment.Whatever the statistics, you are an individual and the complication or success either will or will not happen for you. As you get older, seek doctors who see you as a whole person, not one organ or another. And remember that life inexorably winds down and ends, no matter what you pay and do. Don’t spend it all worrying about your health.
Wall plaque, author unknown
“Life should not be a journey to the grave with the intention of arriving safely in an attractive and well preserved body, but rather skidding in sideways, chocolate in one hand and wine in the other, body thoroughly used up, screaming “WOO HOO what a ride!”
Respond to Health Insurance: How We Became Passengers on a Runaway Train