The latest development appears to be that government-run health insurance programs are, if not off the table, at least sliding toward the edge. Meanwhile, town hall debates rage, Washington lobbyists (outnumbering senators and congressmen by an astounding six to one) hector Congress and the signal-to-noise ratio in the health-care debate steadily deteriorates.
In this shifting and parlous fray, we must carefully delineate the problems that we are trying to fix. Only once this is done should we try to fix them.
I gave my general take on what's amiss in "The Wrong Diagnosis." Now, it's time for more specifics. Here's my assessment of the three main negative trends in American medicine. I discuss each in detail, and propose solutions, in my next book, Why Our Health Matters: A Vision of Medicine that can Transform Our Future, which will be published September 8th, 2009.
Trend #1: Deterioration of Medical Philosophy and Practice
Technology has a shadow side. It accounts for real progress in medicine, but has also hurt it in many ways, making it more impersonal, expensive and dangerous. The false belief that a safety net of sophisticated drugs and machines stretches below us, permitting risky or lazy lifestyle choices, has undermined our spirit of self-reliance. The cold fact is that while Americans live more than 30 years longer than they did at the turn of the last century, public health measures such as better sanitation, immunizations, better food and water, and safer and less polluted workplaces account for 25 years of that increase; medical intervention, only five years. A recent study showed that in the 1990s, only about one in 16,000 Americans had his or her life saved or significantly extended by improvements in health-care technology. "Let's Take the Stomachache Out of Health Care Reform" provides a real-world example of a different approach.
Trend #2: Failure to Provide Health Care for All
Virtually every other developed country has a national health care program. They are not perfect and never will be, but they generally work better than ours. Studies in places such as Germany, France, Scandinavia, the United Kingdom and Canada show that citizens in those countries are happier with their systems than we are, and are healthier as well, with lower rates of obesity and chronic disease. I fully support a national health care program for the U.S.
Trend #3: The Growing Influence of Money
This is the darkest cloud over American medicine. The profit motive, once only a part of health care, now drives the whole system. If current trends hold, a family of four will spend about $64,000 annually for health care in the next seven to nine years (except that they obviously can't and won't - so the system, without reform, will collapse before then).
Virtually all of the incentives run in the wrong direction - that is, toward high-tech interventions to make money rather than toward modest, simple protocols that (in at least 80 percent of cases) make or preserve health. Yet there are pockets of efficiency and effectiveness in America. The nonprofit Mayo Clinic in Rochester, Minnesota, is among the highest quality and lowest cost health-care systems in the country, largely because its salaried doctors have no incentive to drive up costs by over-testing and over-treating. Similarly, at the Arizona Center for Integrative Medicine, we train health care professionals to use only the appropriate level of technology for the condition at hand.
In coming blog posts, I'll propose some detailed solutions to each of these problems. In the meantime, I urge you to read the New Yorker article "The Cost Conundrum: What a Texas town can teach us about health care" by Atul Gawande, M.D. It's an extraordinarily clear-eyed assessment of how and why American medicine has lost its way, and how it might return to its healing roots.