The U.S. spends a massive sum on health care. Would urging behavioral changes and healthier living be the best way to bring down costs?
The limitations of health care have long been a subject of scrutiny. “To Plato, ” the British historian Thomas Babington Macaulay once wrote, “the science of medicine appeared to be of very disputable advantage. He did not indeed object to quick cures for acute disorders, or for injuries produced by accidents. But the art which resists the slow sap of a chronic disease—which repairs frames enervated by lust, swollen by gluttony, or inflamed by wine . . . and prolongs existence when the intellect has ceased to retain its entire energy—had no share of his esteem.”
This perspective is seldom advanced so forthrightly, but such concerns are often hinted at in the contemporary debate about health care. In “More Than Medicine,” Robert M. Kaplan of Stanford’s School of Medicine argues that our enthusiasm for biomedical science has inflated health-care costs while encouraging us to neglect more fundamental determinants of ill health, such as behavior and social conditions. Mr. Kaplan, who served as associate director at the National Institutes of Health during the Obama administration, begins his volume by reciting some familiar facts: The U.S. spends far more on health care (18% of GDP) than Western European nations (about 10%) but has a higher infant-mortality rate and a slightly shorter life expectancy than most other developed nations. He notes that, while health-care spending keeps rising, medical outcomes have even begun to deteriorate.
Unlike many politicians and pundits, however, Mr. Kaplan doesn’t pretend that the situation is simply the result of overpayment for services that could be easily remedied with mandatory price cuts. He suggests, instead, that America’s high spending is the product of a sicker population, a higher intensity of care and the over-medicalization of care at the end of life. The author is skeptical of the capital-intensive innovations that excite investors, and he observes that R&D spending on drug discovery has seen diminishing returns. “To achieve the kind of scientific progress we enjoyed in the early 1970s,” he writes, “takes 25 times as many researchers today.” Mr. Kaplan laments in particular that genomics has not lived up to its promise—the link between genetic defects and disease seems less direct than hoped—and that 1,800 gene-therapy trials had, as of 2012, yielded no cures.
Mr. Kaplan attributes a proliferation of low-value drug therapies to the field’s blinkered focus on biomarkers, such as cholesterol for heart disease or blood-glucose levels for diabetes. Improving particular patients’ measurements on such indicators, he says, may have insignificant effects on overall patient health and survival rates. He argues that colonoscopy screenings do little to reduce premature death, as overall mortality from colorectal cancer among those screened (2.9%) is only slightly less than those unscreened (3.9%), and he expresses fears that increasingly sophisticated diagnostic technologies will lead to many more patients receiving treatments, even though they are suffering no ill effects.
So what does work? Mr. Kaplan credits behavioral change for much of the decline in mortality from stroke and heart disease over recent generations: A public-health crusade helped reduce cigarette consumption per capita by 60% from 1965 to 2014, and the author sees this as a blueprint for dealing with problems like obesity. Yet social interventions are more difficult than he acknowledges: The prohibition of alcohol in the early 20th century seems to have led to a precipitous decline in the incidence of liver cirrhosis, but there is little appetite for similarly intrusive regulations today.
In 2014, 35% of Americans were obese; the average is 17% among other nations that belong to the Organization for Economic Cooperation and Development. Obesity contributes to a greater prevalence of the most expensive medical problems, such as diabetes, heart disease and strokes. But though it may be possible to “nudge” people to reduce soda consumption, obesity in general is often an intractable problem, even for those who are eager to get into shape.
Mr. Kaplan’s many perceptive observations are too often accompanied by policy recommendations that seem impractical or off-base. While he may be right to argue that ending homelessness would improve the health of the homeless, he demonstrates little grasp of this complex social problem other than to breezily propose that ER physicians “could write prescriptions for housing,” which he suggests optimistically “would save on Medicaid bills.”
As Mr. Kaplan contemplates the “social determinants of health,” he discusses the strong association between poverty and such problems as chronic disease, poor diet, substance abuse, lack of access to care, and exposure to environmental hazards. But he too readily mistakes correlation for causation, in this instance and others. From evidence that educational levels are correlated with health he concludes that “ensuring that everyone gets a high school education could prevent an estimated 240,000 deaths per year.” He offers no explanation of how to do this, or any discussion of the complex reasons why people may currently be failing to graduate. His eagerness to spend more on education is also rather ironic, because that sector shares the features for which he criticizes American health care: We spend far more on it than other developed nations but achieve worse outcomes.
Debates about health-care spending often become debates about quality of life. Altogether eliminating diseases like cancer, stroke and Alzheimer’s (which tend to hit those already advanced in age) would only nudge up life expectancy by a few years. Yet these breakthroughs would still be of great value—as are cataract surgeries or knee replacements, which have no effect on life expectancy. “Resisting the slow sap of chronic disease” is something medicine does better than ever.
Mr. Kaplan’s core point is certainly correct: There is more to be gained from a greater focus on preventing illnesses than from spending enormous sums after they strike. Yet that may be a tougher challenge than he imagines in an era when it is easier for politicians to speak of a “right to health care” than to insist on a “responsibility to live healthily.”
This piece originally appeared at The Wall Street Journal
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