A week ago, Andrew Sullivan wrote a thoughtful post about what healthcare reform is apt to mean in the long run.
Remember all those old black and white movies where you saw scenes in which the father of a sick child simply says “we don’t have the money for the operation.” And little Johnny dies. How far away that passive stoicism now seems. Within a few decades, what was once taken as fate is now rejected as a moral obscenity. Because, given what we have achieved in those decades, it is a moral obscenity. We are all physical beings and we are never as equal as when we face sickness and mortality. Because we have so feasted on the tree of knowledge, it becomes morally intolerable to prevent its fruit from being given to all.
At the same time, as a matter of economics and mathematics, we also know at the back of our minds that we simply cannot give it to all – because these breakthroughs involve huge investment, highly trained experts, and inherently expensive technology. And as the options for health grow, we are forced to make choices that were previously out of our grasp, and those choices make us, in some way, gods. We collectively decide who can live for how long and who can die – because for the first time in human history we really have that choice. In fact, we have no escape from that choice. Healthcare is no longer triage, where sickness and death is the norm; it is an open-ended, blurry range of positive choices, where wellness is the expectation.
He goes on to discuss the difficult topic of rationing, with a focus more on the big-ticket items like end-of-life care, chronic illness, etc. This kind of serious question has already become a pressing problem for cash-strapped states, and it demands a serious conversation free of inflammatory, ridiculous distractions.
However, our national conversation cannot focus solely on ICU stays for the terminally ill or expensive investigational drugs. We also have to confront the nickel-and-dime costs that accrue when caring for the well.
The truth is that we consume too much healthcare, and by “we” I mean everyone. Even after squeezing out every possible inefficiency (and believe me, there are inefficiencies galore) paying less for healthcare means getting less healthcare.
As a primary care provider, of course I enjoy the benefits of over-c0nsumption. Parents who opt to have their obviously healthy children checked due to some vague symptom or another are bread and butter for a practice like mine. Over time, one gets to know the families that are intolerant of any symptoms, and who come in multiple times for the same uncomplicated upper respiratory infection because things aren’t better yet! Reassuring anxious parents is as much a part of my job as vaccines or more serious illnesses, and parents who aren’t satisfied with my answer will just go somewhere else to get another opinion anyway.
“Just make sure his ears look OK” visits add up over time. Deciding to go to the local ED for a non-emergent complaint instead of waiting twelve hours for our office to reopen adds up a lot over time. These kinds of patient/parent decisions are hardly unique to my practice, as I imagine anyone staffing an ED could tell you. Insurance (public or private) insulates patients from the cost of this kind of over-utilization, piling ever-higher as an abstract concept instead of being perceived in the same way as fees for other services. (Of course how insulated one is depends a great deal on what kind of insurance coverage one enjoys.)
From what I can tell, this aspect of cost-containment has yet to become part of our conversation. Frankly, I have no idea who has the political courage to say to the American people that they may need to accept being more discerning consumers of health care and getting by with more judicious use. I can’t really imagine President Obama saying “you’ll have to go to the doctor’s office less” and surviving; one may as well slap a cardigan on him now and be done with it. But we cannot truly address how much we spend for medical care without acknowledging how we all contribute to the tally, in ways big and small.