The Choice: A Longer Life or More Stuff

By DAVID LEONHARDT
Published: September 27, 2006

The most authoritative report on the cost of health insurance came out
yesterday, and it's sure to cause some new outrage.

Life Expectancy Data (September 27, 2006) Kaiser Family Foundation
report

The average cost of a family insurance plan that Americans get through
their jobs has risen another 7.7 percent this year, to $11,500,
according to the Kaiser Family Foundation. In only seven years, the
cost has doubled, while incomes and company revenue, which pay for
health insurance, haven't risen nearly as much.

These spiraling costs - a phrase that has virtually become a prefix
for the words "health care" - are slowly creating a crisis. Many
executives have decided that they cannot afford to keep insuring their
workers, and the portion of Americans without coverage has jumped 23
percent since 1987.

An industry that once defined the American economy, meanwhile, is
sinking in large measure because of the cost of caring for its workers
and retirees. For every vehicle that General Motors sells, fully $1,500
of the purchase price goes to pay for medical care. "We must all do
more to cut costs," G.M.'s chief executive, Rick Wagoner, said on
Capitol Hill this summer while testifying about health care.

Mr. Wagoner's argument has become the accepted wisdom about the
crisis: the solution lies in restraining costs. Yet it's wrong.
Living in a society that spends a lot of money on medical care creates
real problems, but it also has something in common with getting old.
It's better than the alternative.

To understand why, it helps to look back to a time when Americans
didn't worry much about health care costs. In 1950, the country spent
less than $100 a year - or $500 in today's dollars - on the
average person's medical care, compared with almost $6,000 now, notes
David M. Cutler, an economist who wrote a wonderful little book in 2004
titled, "Your Money or Your Life."

Most families in the 1950's paid their medical bills with ease, but
they also didn't expect much in return. After a century of basic
health improvements like indoor plumbing and penicillin, many experts
thought that human beings were approaching the limits of longevity.
"Modern medicine has little to offer for the prevention or treatment
of chronic and degenerative diseases," the biologist René Dubos
wrote in the 1960's.

But then doctors figured out that high blood pressure and high
cholesterol caused heart attacks, and they developed new treatments.
Oncologists learned how to attack leukemia, enabling most children who
receive a diagnosis of it today to triumph over a disease that was
almost inevitably fatal a half-century ago. In the last few years,
orphan drugs that combat rare diseases and medical devices like the
implantable defibrillator have extended lives. Human longevity still
hasn't hit the wall that was feared 50 years ago.

Instead, a baby born in the United States this year will live to age 78
on average, a decade longer than the average baby born in 1950. People
who have already made it to their 40's can now expect to reach age
80. These gains are probably bigger than the ones the British
experienced in the entire millennium leading up to 1800. If you think
about this as the return on the investments in medicine, the payoff has
been fabulous: Would you prefer spending an extra $5,500 on health care
every year - or losing 10 years off your lifespan?

Yet we often imagine that the costs and benefits are unrelated, that we
can somehow have 2006 health care at 1950 (or even 1999) prices. We
think of health care as if it were gasoline, a product whose price and
quality have nothing to do with each other.

There is no question that the American medical system does suffer from
a lot of waste, be it insurance industry bureaucracy or expensive
procedures that haven't been proven effective. But the No. 1 cause of
the cost increases is still the one you can see at the hospital and in
your medicine cabinet - defibrillators, chemotherapy, cholesterol
drugs, neonatal care and other treatments that are both expensive and
effective.

Not even most forms of preventive care, like keeping diabetes under
control, usually save money, despite what many people think. The care
itself has some costs, and, more important, patients then live longer
than they otherwise would have and rack up medical bills. "When I
make this point, people accuse me of wanting people to die earlier. But
it's exactly the opposite," Dr. Jay Bhattacharya, a researcher at
Stanford Medical School, told me. "If these expenditures are keeping
people alive, it's money well spent."

As Dr. Mark R. Chassin of the Mount Sinai School of Medicine in New
York says, "You almost always spend money to gain health." Of
course, the opposite is also true: the best way to reduce health care
spending is to reduce health care itself.

Which is exactly what we're starting to do. The growing number of
families without health insurance are, in effect, families who have
been kicked off the country's health care rolls. Many will go without
available treatment, will get sicker than they need to get - and will
thereby save the rest of us money. They are what now passes for a
solution to the health care mess.

The current situation is indeed unsustainable, a point that the
conventional wisdom has right. The cost of health insurance can't
keep doubling every seven years, and wasteful spending - the
brand-name drugs that are no better than generics, the treatments that
haven't been proved to extend lives or improve health - does need
to be reined in.

But far too much of the discussion has been centered on this narrow
idea. Somehow, going to the mall to buy clothes has come to be seen as
a vaguely patriotic way to keep the economy humming, and taking out a
risky mortgage is considered to be an investment in one's future. But
medical care? That's just a cost.

It's easy to be against high costs, and it will no doubt be hard to
come up with a broad health care solution. But the way to start is by
acknowledging that an affluent society should devote an ever-growing
share of its resources to the health of its citizens. "We have enough
of the basics in life," Mr. Cutler, the economist and author, points
out. "What we really want are the time and the quality of life to
enjoy them."

E-mail: leonhardt@nytimes.com

---- my response -----

Dear Mr. Leonhardt,

I was very perplexed to read your article, "The Choice: A Longer Life
or More Stuff."  In it, you make the assumption that increasing
healthcare costs are linearly linked (or even roughly associated) to an
increase in longevity over time.  This premise is not only unproven, it
is soundly disproven.

  ----

Absolutely correct.  But what do you expect from an undereducated economics
reporter who only spouts what he is told?

Very nice, Peter, but I was a little surprised that you didn't call him
on his mention of cholesterol drugs.  It's becoming more and more
understood that those drugs do not increase longevity.

Let us know if you get any kind of reply... but I won't be holding my
breath.  :)

Max.

EXCELLENT!  Keep up the good work, Peter.

God Bless,

Jan

The Choice: A Longer Life or More Stuff

By DAVID LEONHARDT
Published: September 27, 2006

The most authoritative report on the cost of health insurance came out
yesterday, and it's sure to cause some new outrage.

Life Expectancy Data (September 27, 2006) Kaiser Family Foundation
report

The average cost of a family insurance plan that Americans get through
their jobs has risen another 7.7 percent this year, to $11,500,
according to the Kaiser Family Foundation. In only seven years, the
cost has doubled, while incomes and company revenue, which pay for
health insurance, haven't risen nearly as much.

These spiraling costs - a phrase that has virtually become a prefix
for the words "health care" - are slowly creating a crisis. Many
executives have decided that they cannot afford to keep insuring their
workers, and the portion of Americans without coverage has jumped 23
percent since 1987.

An industry that once defined the American economy, meanwhile, is
sinking in large measure because of the cost of caring for its workers
and retirees. For every vehicle that General Motors sells, fully $1,500
of the purchase price goes to pay for medical care. "We must all do
more to cut costs," G.M.'s chief executive, Rick Wagoner, said on
Capitol Hill this summer while testifying about health care.

Mr. Wagoner's argument has become the accepted wisdom about the
crisis: the solution lies in restraining costs. Yet it's wrong.
Living in a society that spends a lot of money on medical care creates
real problems, but it also has something in common with getting old.
It's better than the alternative.

To understand why, it helps to look back to a time when Americans
didn't worry much about health care costs. In 1950, the country spent
less than $100 a year - or $500 in today's dollars - on the
average person's medical care, compared with almost $6,000 now, notes
David M. Cutler, an economist who wrote a wonderful little book in 2004
titled, "Your Money or Your Life."

Most families in the 1950's paid their medical bills with ease, but
they also didn't expect much in return. After a century of basic
health improvements like indoor plumbing and penicillin, many experts
thought that human beings were approaching the limits of longevity.
"Modern medicine has little to offer for the prevention or treatment
of chronic and degenerative diseases," the biologist René Dubos
wrote in the 1960's.

But then doctors figured out that high blood pressure and high
cholesterol caused heart attacks, and they developed new treatments.
Oncologists learned how to attack leukemia, enabling most children who
receive a diagnosis of it today to triumph over a disease that was
almost inevitably fatal a half-century ago. In the last few years,
orphan drugs that combat rare diseases and medical devices like the
implantable defibrillator have extended lives. Human longevity still
hasn't hit the wall that was feared 50 years ago.

Instead, a baby born in the United States this year will live to age 78
on average, a decade longer than the average baby born in 1950. People
who have already made it to their 40's can now expect to reach age
80. These gains are probably bigger than the ones the British
experienced in the entire millennium leading up to 1800. If you think
about this as the return on the investments in medicine, the payoff has
been fabulous: Would you prefer spending an extra $5,500 on health care
every year - or losing 10 years off your lifespan?

Yet we often imagine that the costs and benefits are unrelated, that we
can somehow have 2006 health care at 1950 (or even 1999) prices. We
think of health care as if it were gasoline, a product whose price and
quality have nothing to do with each other.

There is no question that the American medical system does suffer from
a lot of waste, be it insurance industry bureaucracy or expensive
procedures that haven't been proven effective. But the No. 1 cause of
the cost increases is still the one you can see at the hospital and in
your medicine cabinet - defibrillators, chemotherapy, cholesterol
drugs, neonatal care and other treatments that are both expensive and
effective.

Not even most forms of preventive care, like keeping diabetes under
control, usually save money, despite what many people think. The care
itself has some costs, and, more important, patients then live longer
than they otherwise would have and rack up medical bills. "When I
make this point, people accuse me of wanting people to die earlier. But
it's exactly the opposite," Dr. Jay Bhattacharya, a researcher at
Stanford Medical School, told me. "If these expenditures are keeping
people alive, it's money well spent."

As Dr. Mark R. Chassin of the Mount Sinai School of Medicine in New
York says, "You almost always spend money to gain health." Of
course, the opposite is also true: the best way to reduce health care
spending is to reduce health care itself.

Which is exactly what we're starting to do. The growing number of
families without health insurance are, in effect, families who have
been kicked off the country's health care rolls. Many will go without
available treatment, will get sicker than they need to get - and will
thereby save the rest of us money. They are what now passes for a
solution to the health care mess.

The current situation is indeed unsustainable, a point that the
conventional wisdom has right. The cost of health insurance can't
keep doubling every seven years, and wasteful spending - the
brand-name drugs that are no better than generics, the treatments that
haven't been proved to extend lives or improve health - does need
to be reined in.

But far too much of the discussion has been centered on this narrow
idea. Somehow, going to the mall to buy clothes has come to be seen as
a vaguely patriotic way to keep the economy humming, and taking out a
risky mortgage is considered to be an investment in one's future. But
medical care? That's just a cost.

It's easy to be against high costs, and it will no doubt be hard to
come up with a broad health care solution. But the way to start is by
acknowledging that an affluent society should devote an ever-growing
share of its resources to the health of its citizens. "We have enough
of the basics in life," Mr. Cutler, the economist and author, points
out. "What we really want are the time and the quality of life to
enjoy them."

E-mail: leonhardt@nytimes.com

---- my response -----

Dear Mr. Leonhardt,

I was very perplexed to read your article, "The Choice: A Longer Life
or More Stuff."  In it, you make the assumption that increasing
healthcare costs are linearly linked (or even roughly associated) to an
increase in longevity over time.  This premise is not only unproven, it
is soundly disproven.  The pharmaceutical makers are often lauded for
their developement of vaccines as the greatest advance in modern
medicine for use in public health.  In reality, not more than 3.5% of
the decline in infectious disease mortality during the period 1900 to
1975, was concomitant with use of vaccine.  [Ref: J.B. & McKinley S.M.
McKinley.  The Questionable Effect of Medical Intervention in the
Decline of Mortality in the United States in the Twentieth Century.
Milbank Memorial Fund Q. 1977; 55:405-28.  Also quoted in Public Health
at the Crossroads, by Robert Beaglehole and Ruth Bonita.]  Despite its
widespread use, there is no evidence that vaccine is responsible for
the majority of declines even in this largest area of public disease
risk.  Consequently, a rise in the standard of living is the only
logical explanation for improvements in public health over the past
century.  The concomitant use of pharmaceuticals during the same time
frame is in no way evidence that drugs should take credit for this.
The absence of substantial randomized and controlled studies in use of
vaccine, whether funded by the drug makers or independently undertaken,
underscores this fact.

Your comment that chemotherapy represents "effective" medicine is also
based largely on promotional material provided by the drug makers.  The
percentage of cancers for which this class of drug is effective falls
well below 5%, and even that depends on your definition of "effective."
 The shrinking of tumors, for example, is not equivalent to either
remission or longer life, and the majority of cancers in which
chemotherapy is used are not responsive to it at all.  In fact, the
data show there is virtually no difference in survival times for cancer
victims today than for those who lived fifty years ago.  The very small
percentage who do seem to respond favorably have not been subjected to
randomized trials, and thus we have no way of knowing to what extent
medication, or some other aspect of palliative care, including
nutraceutical support, may be responsible.

Where is the integrity in journalism today that asks the hard questions
about the "evidence" in "evidence based" medicine?  If there a reason
to sugar coat the facts in reporting medical "stories" that goes beyond
assaging public angst over the profit-driven rise in healthcare costs,
perhaps that is the real story.

Thank you for your time and I hope you realize that the public knows
responsible journalism when it sees it, and when it doesn't.

PeterB