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November 11, 2005

Quality, Not Longevity

Kevin gets a lot right here. Both Tyler and Matt are correct that massive new expenditures on health care wouldn't raise life expectancy much (although, for the uninsured, of whom 18,000 or so die each year due to lack of appropriate health care, access to services would make a life expectancy difference), but they're barking up the wrong tree. Once you reach a baseline of medical spending, technology utilization, and trauma centers, you've basically done your part to keep folks alive. From there, prevention is really the name of the game, increased spending won't do much at all.

It's easy, particularly in this country, to think of health care as a primarily trauma-based enterprise. That, after all, is where much of the money goes. But of all the various facets in American health services, trauma care is probably the least fucked up. You could argue back and forth on the economic merits of what we do for the very old and ill, but we are delivering those services to almost everyone who needs them.

It is, instead, the young and spry, not to mention the middle-aged but well-preserved, who miss out on a variety of treatments and services that could vastly improve their quality of life not only now, but as they get older (back problems that go untreated and worsen with time, forms of scoliosis, etc). And doing a better job at covering them and opening the pathways towards preventive, smart care, isn't even very expensive. But it does require a system where the gatekeepers aren't compelled to cut costs by cutting corners. It's much easier to ignore someone's lingering, marginal problem and save a couple bucks than to stiff a hospital on their treatment of a guy who fell down the stairs. And so that's exactly what they do.

It's telling that the the report Cowen references to show that health spending doesn't matter uses the RAND Study, which found that copays vs. free care have much affect on the amount of health care used and little affect on the quality. That's quite true. Which is why you don't hear many progressives agitating for more care for the rich. So long as folks have adequate medical coverage (and all in the study did), they can and will get treatment at most all necessary times. The questions with health insurance are whether or not those necessary times should bankrupt less-wealthy individuals, be subsidized for poor individuals, and be made cheaper through cost-containment and coherent delivery strategies, and whether or not the entire system can be run more efficiently. Many Americans are using way more care than they need, but a significant portion are using far less. And all Americans, due to the absurdities, inefficiencies, and perverse incentives of the health care market, are using more expensive care than they must. We can fix that.

By the way: Did anyone else notice that Tyler Cowen's "If I were a Democrat" post on health care basically said, If I were a Democrat, I'd think of health care as if I were a libertarian-leaning economist resigned to a certain degree of statism? In other words, if I were a Democrat, I'd think of health care as if I were Tyler Cowen, who isn't a Democrat. I can't imagine why the party hasn't thought of that yet!

November 11, 2005 | Permalink


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Two things, Ezra.

Trauma care is indeed problematic. Check out this article all about ER docs pleading for help: http://www.acep.org/webportal/Newsroom/NR/General/RallyRelease.htm ERs are closing around the nation, they have absurd wait times, etc.

It will cost money to enact better preventative care, although it will save in the long run. While we don't need a "massive increase in spending", certainly $$ and infrastructure is needed to establish better preventative care practices.

Posted by: Kate | Nov 11, 2005 4:37:10 PM

Yeah, if you reduce inequality in the country you'd raise life expectancy, or so Michael Marmot seems to claim. It is definitely plausible that giving poor people more health care increases life expectancy, but not rich people. Though the reduced life expectancy of poor people is partially health care and partially many many other factors...

Posted by: Isaac | Nov 11, 2005 5:40:29 PM

Did anyone else notice that Tyler Cowen's "If I were a Democrat" post on...

I continue to wonder why anyone on this side of the political divide takes any advice from anyone on that side. Listen to their best arguments for their own positions, sure. That can be useful (when it's not as far from actual fact as most of the Republicans have gotten).

But any post, speech, or other communication purporting to be advice? It's always going to be useless, because what they want is a world in which both parties represent their interests.

This is, incidentally, the obvious program of Marshall Wittman, and to a lesser and less obvious extent of other corporate-money "centrists".

Posted by: paperwight | Nov 12, 2005 12:36:53 AM

Best place to study the inadequacies of health care is an emergency room in an inner city. Count the number of sick children. The kids are there to be treated for sore throats, colds, and every other thing kids can get. Their parents don't have family doctors. They can't afford to take time off from work during the day to take the kids to the doctor. Besides the fact that using the ERs as family practices costs the rest of us money, it also means that kids are not getting checkups, shots, etc. and that costs them not in life expectancy but in quality of life. But it costs the rest of us in that these kids come to school sick which is far from the best condition in which to learn. I think I'm headed towards a long post on creating a culture of muddling through, making do, and putting up with problems that results in a culture of defeatism---"Life stinks, what's the use?" Obviously adequate health care wouldn't be a fix-all---good schools, good job prospects, safe neighborhoods are needed too---but it's easier to deal with other problems when you don't feel sick all the time.

Posted by: Lance Mannion | Nov 12, 2005 12:56:41 PM

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