On inequality and healthcare

Note: This post is part of our League Symposium on inequality. You can read the introductory post for the Symposium here. To see a list of all posts in the Symposium so far, click here.

Nothing is so equalizing as morbidity and mortality.  As a song of which I am particularly fond puts it, both the slave and the empress will return to the dirt.  Rich or poor, tenured professor or high school drop-out, marathon runner or sedentary lump — injury, disability and disease will find us all eventually.  True, it helps to be affluent, educated and active, but we’re all going to shuffle off this mortal coil sooner or later.  And just about all of us will need healthcare to mitigate that unpleasant reality to some extent or another.  (Those of you struck from above by falling pianos, congratulations on beating the system.)

(I thought I would start things on an “up” note.)

Further, it is difficult to predict with certainty when and to what degree people will need medical care.  You can be the most sensibly-exercising, moderately-imbibing, scrupulously healthy eater on the planet and still find a lump on your testicle or breast.  Life offers no guarantees.  That said, the truth is the majority of people don’t need a lot of care to maintain their usual state of good health.  Most of us are mostly healthy most of the time.

Which leads to one of the hard facts about medical care in this country.  It is grossly unequal in its distribution.  From the U.S. Department of Health and Human Services:

As policymakers consider various ways to contain the rising costs of health care, it is useful to examine the patterns of spending on health care throughout the United States. In 2004, the United States spent $1.9 trillion, or 16 percent of its gross domestic product (GDP), on health care. This averages out to about $6,280 for each man, woman, and child.

However, actual spending is distributed unevenly across individuals, different segments of the population, specific diseases, and payers. For example, analysis of health care spending shows that:

• Five percent of the population accounts for almost half (49 percent) of total health care expenses.
• The 15 most expensive health conditions account for 44 percent of total health care expenses.
• Patients with multiple chronic conditions cost up to seven times as much as patients with only one chronic condition. [emphasis added]

And who comprises that five percent?

The average health care expense in 2002 was $11,089 per year for elderly people but only $3,352 per year for working-age people (ages 19-64).⁵ Similar differences among age groups are reflected in the data on the top 5 percent of health care spenders. People 65-79 (9 percent of the total population) represented 29 percent of the top 5 percent of spenders. Similarly, people 80 years and older (about 3 percent of the population) accounted for 14 percent of the top 5 percent of spenders… However, within age groups, spending is less concentrated among those age 65 and over than for the under-65 population. The top 5 percent of elderly spenders accounted for 34 percent of all expenses by the elderly in 2002, while the top 5 percent of non-elderly spenders accounted for 49 percent of expenses by the non-elderly.⁴

And those chronic conditions?

One study found that a small number of conditions accounted for most of the growth in total health care spending between 1987 and 2000—with the top five medical conditions (heart disease, pulmonary disorders, mental disorders, cancer, and trauma) accounting for 31 percent.¹⁶ For 7 of the top 15 conditions, a rise in the proportion of the U.S. population being treated, rather than rising treatment costs per case or population growth, accounted for the greatest part of the spending growth.

In summary, the small percentage of the population who account for almost half of our expenditures are either people who have survived long enough to be struck by the illnesses of the aged, the mentally ill, or people who have suffered some kind of catastrophic medical event (cancer, trauma).  Since (pace The Who) living a long life beats the alternative, all of us have the potential to land in that five percent, sooner if disaster strikes.  This inequality of need is likely to persist for perpetuity, and I don’t think anyone can plausibly deny its intractability.  Sicker people will always need more care, and older people are likely to be sicker.

Where things begin to unravel is what happens when we do enter (or even approach) that five percent.  We (patients, physicians and policy makers) lack a coherent notion of what constitutes reasonable care at the extremes of infirmity or illness.  Some patients benefit from the tens of thousands of dollars spent on them, some do not, and it can be terribly difficult to tell them apart.  But not only do we lack of paradigm for approaching these fraught questions, we lack the means of getting there anytime soon.

Raise your hand if you remember the “death panels” debate.  (Keep your hand up indefinitely if you remember it fondly.)  That whole ridiculous brouhaha erupted over the perfectly reasonable provision in the Affordable Care Act that would have reimbursed physicians for time spent discussing end-of-life care with their patients, despite several prominent conservatives having thought it was a good idea once upon a time.  Given that in the next several years healthcare costs are expected to exceed the growth of the economy by over a percentage point and comprise nearly 20% of GDP by 2020 [PDF], we must be able to have honest policy conversations about what kinds of care are worth paying for without rapidly devolving into partisan rancor.  I wish I were optimistic about the odds of that happening.

As satisfying as it is to hurl contempt at Sarah Palin, the medical community is still in the early stages of learning how to address these issues, too.  Medicine still views disease more as an enemy to be defeated at all costs than an inevitable reality to be ameliorated.  In a 2003 study, a mere 18% of medical students and residents reported being taught anything about end-of-life care.  While there seems to be growing acknowledgment on the part of medical educators that this is a gap that ought to be closed, that’s just the very first baby step toward where we need to be.  It doesn’t help much for the government to reimburse us for conversations we’re unwilling or unable to have.

Unfortunately, I suspect our culture at large plays into this, as well.  A casual stroll by the newsstand yields an avalanche of publications and articles all about remaining hale, healthy and beautiful forever and ever.  (Never mind that within the span of a few days you can read three different articles in the paper of record telling you that exercise is good for you, may kill you, or is fine if you do it the right amount.)  Even a simple pleasure like your morning cup of coffee now comes laden with health claims.  The implication underlying our national obsession with wellness is that proper diligence will forestall the depredations of age, and infirmity is a moral failure.  If you develop one of those pricy chronic conditions, chances are you exercised wrong.  And if, God forbid, you’re overweight or smoke then you’re veritably asking the Grim Reaper over for tea.  Shame on you.

Yes, we all have some responsibility for our own health.  Yes, the increasing obesity rates in this country are certainly contributing to our burgeoning health costs.  (Those of you with your hands still raised may lower them if you have a cogent solution to that problem.)  Yes, it is worthwhile to encourage good attention to preventive care.  But it seems to me that our national healthcare conversation is skewed.  A substantial portion of our healthcare dollars is spent on care that nobody wants to talk about.

It is so much safer politically and happier for everyone to focus on the ounce of prevention.  But the pounds of cure (which are often necessary and beneficial) will keep piling up if nobody has the nerve to ask how we might go about trimming them.