The Future of Medical Care (And Health Care)

The current problems regarding medical care in this country has become obscured. Even the topic is unclear. We have a "health care" problem which implies a slightly different problem than the problem most people are experiencing. The problem is not about "health care." Regardless of the publicity and the debates, the problem with medical care is what it costs.

Availability of medical care is not the question. I have never once seen a person deprived of medical attention because of money. The care is always available because the people who practice medicine--the physicians, the nurses, the PA's--have taken a vow to take care of sick people. The vows they take specifically prohibit the abuse of the inequality that exists between patient and caregiver, the vulnerability that his illness gives him.

And while insurance is a problem, it is not the main problem. It is not even the problem it is cracked up to be. According to the Census Bureau there may be up to 47 million people without health insurance. Of those, 18 million come from households with incomes of over $50,000 annually (more than the medical resident who would see him), 10 million from households of over $75,000. 10 million are not American citizens. Another 10 million are eligible for Medicaid but have not applied. Their reasons for not having insurance may be interesting, may be sad or even stupid. They may stimulate many tax deductible conferences. But the noble goal of having these people insured is not the point. The high cost of medical care is the point.

And there is the conceit that the government (the government!) might be able to improve medical care. The government! Some point to those strange studies from the U.N. that rank states on medical care quality. Aside from credibility questions (Castro, Chavez, Mugabe have great ability to apply statistical analysis to their electricity-free nations and would never lie) these studies have some fascinating assumptions. For example, a nation that does not have a central medical service is automatically downgraded. Ditto large nations. If you have high expectations of your medical system and are disappointed that nation is downgraded, if you expect little and are pleasantly surprised, upgraded. And there is no standardization. A newborn death in the first 24 hours of life is a death in the U.S., a miscarriage in Britain and France. The major non genetic cause of infant death is prematurity and low birth weight; these are functions of smoking, teenage mothers and race (Afro-Americans have a very high prematurity regardless of circumstances). These are social factors, not medical.

But even if the government could improve medical care, it is a side point. The problem in this country is the cost of medical care.

This country has developed highly selected, well educated people to apply complex surgery, expensive devices and advanced pharmaceuticals quickly to ill people. There are few wards; there are many private hospital rooms. The nurses are extremely well educated and available. Transport to plentiful facilities is managed from anywhere in the country to any select institution. In short, this is an expensive system. All of this comes at a cost. And many think that cost is too high. I do not know how that is determined; we have an older population, they want care and are willing to pay for it. Ewe Reinhold thinks that uncontrolled health costs can digest the whole economy. These theoretical questions are interesting and peripheral; medical costs in this country are too high.

The answer here is not to improve insurance, not to make medical care more available, and not to have the government bring its version of "expertise" to the science of medicine. Medical cost are high and increasing because the medical care those costs support is of high calibre and growing. Soon we will all be priced out of the Maserati medical market. The answer will be to build a Chevy. The effort to increase the number of people covered by insurance is cynically deceptive. The answer to high health care costs is to have less medical care. The government knows this and will start the process by simply paying less and less for more and more of what it receives. The consequences of decreasing price paid for a product or service without consideration of underlying costs is simple as well: The product or service goes away. That will result in medical care that is less available, less prompt, and less good. That will cause some major changes, but decreasing medical costs will not occur in any other way.