Most of the debate on how to solve the nation’s crisis in establishing health care for Americans ignores the basic drivers of cost, which in aggregate put us between the proverbial “rock and a hard place.” The bottom line: What care we can’t pay for will not get done, no matter how it is financed. Immutable facts make this clear.
The cost of health care is driven by how much care needs to be provided. While this seems intuitively obvious, determining exactly how much care is needed is driven by an incredibly complex set of factors involving disease burden, medical necessity and standards of care, tempered by consumer perception and demand.
Medical necessity is an incredibly elusive term, driven by known medical outcomes under varying degrees of severity of the condition under consideration, balanced by cost and demand.
Outcome is a medical/research based set of decision points on when care is likely to be most effective. When to do care, or delay until outcomes are optimal (elective surgical procedures are the best example), can be defined with associated cost. These are often contrary to consumer demand, hence the specter of “rationing,” which quickly takes the debate from objective to emotional.
They also impact profit margins of providers, health care organizations and pharma. Put simply, the issue is the tension between “medical necessity” and “free market.” (The essence of American aversion to single-payer systems.) The complexity is staggering. But no matter how we come up with quantifying it, the amount of medical care needed in the United States is significantly higher than the resources currently dedicated to provide it.
The United States, by most measures, is the unhealthiest nation on Earth. We are driving a cost of care that per capita is the highest in the developed world. The explosion of obesity and diabetes alone will sink us in the future. The demand for care exceeds resourcing now, and it will only get worse.
Medical innovation is driving new treatments daily – all staggeringly costly. Medically caused disasters like the opioid crisis add incalculable unmet cost to future health care resourcing.
Fact: Medical expenditures in the United States have risen, conservatively, an unsustainable 5 percent per year over the last decade. This an immutable fact, even if one ignores all the above. Any plan that attempts to “save” the federal government $313 billion over the next 10 years (the latest Senate health care bill) cannot do so without shifting the cost to the individual in some form. Or reducing care. The hope of saving this amount of money through “efficiency” is simply a falsehood. Unless we solve the riddle in the first paragraph above. It’s not going to happen in 10 years.
Hence the rock and a hard place: Americans will either face a future of less health care (with high likelihood of increasing disparity of who gets it) or a major increase in how much we pay. There is no third alternative. Unless we get healthy. And accept the realities of medical necessity. A long time in coming at best, highly unlikely at worst. In the meantime, we will thrash about who doesn’t get care.
There is no health plan that will avoid this without, at least initially, increasing how much of our Gross Domestic Product we spend, which amounts to some sort of increase in taxation, or cost shifting, to the “haves” to assist the “have nots.”
President Donald Trump, not one for understatement, hit the nail on the head on this one: “This is HARD!” Unfortunately, the principals in the debate, through personal circumstance or taxpayer provided medical care, are immune to the realities of the rock and a hard place.
It is left up to the rest of us to determine the “least worst” and make it known to them.
(Jon Pearse is a retired Air Force family physician. He lives in Concord.)