Big question. Most of us try and narrow it down to one or two chief factors. As with many things in life, to do that is really ignoring the cause of the problem and latching on to one or two things you really disagree with. Let's see what the deal really is...
Since the sharp rise in technological health care innovation in the 90's, the cost of healthcare has gone up at roughly 4-4.5 times the rate of the consumer price index.
First -- What's killing people?
All the way back in 1900, the leading cause of death could be broken down as such:
1900 (life expectancy at 47.5 years, mainly due to high infant mortality)
Pneumonia - 11.7%
Tuberculosis - 11.3%
Diarrhea - 8.3%
Heart disease - 8.0%
Stroke - 8.0%
Liver disease - 5.1%
Injuries - 4.2%
Cancer - 3.7%
Senility - 2.9%
Diphtheria - 2.3%
2009 (life expectancy: 78.3 years)
Heart disease - 34.1%
Cancer - 30.2%
Stroke - 7.5%
Emphysema - 6.7%
Injuries - 6.4%
Alzheimer's - 3.9%
Diabetes - 3.9%
Pneumonia/flu - 3.1%
Kidney disease - 2.4%
Sepsis - 1.8%
So, what do you notice? In 1900, and up to the 50's really, lifestyle diseases and age diseases weren't really complicit in killing all that many people to how things are now. As of a couple years ago, the amount of us making it through birth and on to a late age is astoundingly higher than even in our grandparents generation. It's pretty incredible, really, but consider the treatment required to deal with today's leading killers.
Today, some of the leading causes of death are heart disease, cancer, stroke, chronic respiratory diseases, unintentional injuries and diabetes. These are the listed causes of death, but what are the actual causes of most of these? Tobacco use, poor diet*, lack of activity*, alcohol consumption, microbial agents, toxic agents, motor vehicle accidents, firearms, sexual behaviors and illicit drug use (* these two are estimated to have been the primary cause in 35% of all deaths in 2008)
Let's focus in on diet and exercise. That's a lot of deaths, but is it spread out evenly across the country? Not really:
I love southern cooking as much as the next guy, but let's not kid ourselves about how it is for your health. Clearly, this relates to obesity trends.
And how does this relate to health? Nine of the ten states in the south are in the top ten in terms of obesity in the US. All ten states in the south are the top ten states for per capita cases of diabetes and hypertension (obesity-related issues were related to 9.1% of all medical spending the US in 2009
And what else are we talking about with obesity? In my estimation, soda is the biggest deal we're looking at these days. Soda consumption has gone up 300% in the last 20 years. More than 75 gallons of soda are consumed for every man, woman and child per year.
That's a lot. Right now, the average American consumes 165 lbs of simple sugars per year. How does that compare to diets of the past?
1910 - 4lbs/year
1986 - 127lbs/year
2005 - 148lbs/year
Why was it such a big deal when supersized meals were facing legislation? Among all fast food restaurants, sizing up usually costs about $0.67 per meal. In turn for that 17% increase in price, you get 73% more calories (the empty ones, at that).
This is how everything adds up:
33% among American adults
17% among European adults
The health impact of that is that the average American adult is 50% more likely to experience unhealthy high blood pressure or diabetes in their life, and twice as likely to develop heart disease or arthritis. So, what's the cost impact of all this?
Average US annual medical bills:
Obese patient: $4,871
Healthy weight patient: $3,442 And who pays for all of this?
Insurance companies and public health care options. Much more often than not, this cost in put on all of us.
And how do we stack up? Why does this happen?
There have been literally volumes written on this, but the reality is that for most of us, the unhealthy option is far, far easier than the healthy one. For instance, my drive to work is almost 2 miles on the dime through Portland's central east side. On my way to work, I pass two Popeye's Chickens, two McDonald's, two Burger Kings, a Taco Bell, a Wendy's, a Burgerville, two drive thru Starbucks and ONE grocery store. Anything wrong with this picture?
Personal responsibility is at the core of the issue here, but to those of you that believe the issue ends there, I will point out to you the proliferation of fast food, soda and fry consumption and obesity in this country. That's fine if you believe it ends there, but all you'll end up doing is riding this wave of medical costs, whether or not you're making good decisions for yourself.
The other thing that goes overlooked is what people think about this:
When asked about the contributing factors in a KFF poll, only 29% of respondents cited unhealthy lifestyle choices as a major contributing factor i.e. "It's not my fault, it's all those other culprits."
44% of respondents said they shouldn't bear any part of responsibility for their healthcare.
And the best one of all...
90% of respondents described their diet as healthy.
Let's take a look at the end result. Remember that obesity map?
Compare that with the life expectancy map: What other areas of health care does this touch on?
So, as most of us know (some don't accept it) the vast majority of the civilized world considers two outcomes when looking at the level of social development for a country: Life expectancy and infant mortality. If you don't choose to believe it, that's a discussion for another thread, but just roll with me for a bit here.
Utilization of health care during child birth -- cesarean deliveries:
15% of all surgeries performed in the US
32% of all US hospital childbirths in 2007, up 50% over the prior 10 years
10% of all cesarean births are done upon mother's request with no necessary medical reason
Yet, according to a study of six million US hospital births, the mortality rate among voluntary c-section was 1.77/k, and only 0.62/k. Women are nearly three times more likely to lose their child during c-section, yet more and more are voluntarily opting for it. Why?
And our health does
have a direct cause on premature birth rates.
Vermont (best state in US): 9.5%
What are the direct, traceable, scientifically indicated causes of premature birth? Income level, lack of prenatal care (no insurance, poor education), obesity, diabetes, high blood pressure, fertility clinics, multiple embryos
What are the results of preterm births?
Brain damage, intellectual disabilities, blindness, hearing loss, etc. These all amount up to unnecessary, avoidable additional cost to our healthcare system through utilization. When is enough enough?
I touched on in vitro fertilization earlier. The practice is how 'octomom', for instance, gave birth to all 14 of her kids. She recently told Oprah she's starting to regret her decision to have all those kids. Ya think?! If she wasn't able to get appearance fees for $100,000, or appearances on Oprah, etc., she'd be on the government tit. She raises all her kids full time and still has to employ three nannies and spend $1,000 a month in groceries.
This all points, however, to excessive in vitro practices, and the bottom line is that it costs all of us money to prop it up. It's a wonderful practice, don't get me wrong, to give a women the ability to bear children who couldn't do so otherwise, but there are some piss poor ethics behind this, on part of doctors and patients for selfish reasons.
Next, technological development.
Tech development has done some great things. For instance, Providence St Vincent here in Portland has one of five particular MRI machines in north America and IIRC the only one on the west coast, which allows for an MRI to be performed in the middle of brain surgery, which is incredibly helpful. That machine costs $5,000,000.
There's other great stuff, like the Heart Pump II, which is used while somebody waits for an available heart transplant. It provides a 58% survival rate over the course of two years. Pretty widely used device. How much does it cost? $125,000: $80k for the pump, $45k for the surgery.
But is technology always the new answer? Consider the CT scan:
In terms of radiation exposure:
1 head CT scan = 30 chest x-rays
1 chest CT scan = 119 chest x-rays
1 abdomen CT scan = 234 chest x-rays
The CT scan, while saving thousands of lives, has also been a major cause in the doubling of average radiation exposure since 1980. The CT scan has been an estimated cause of 29,000 new cases of cancer and 14,500 deaths per year. Getting two CT scans gives one the same amount of radiation as if they stood two miles away from ground zero at Hiroshima. Yet since 1990, the proliferation of CT scans has gone up astronomically.
New technology has its uses, but sometimes, like this one, it comes with an extreme amount of cost, both monetary and otherwise. Yes, lawyers are in on this party too.
It is currently estimated that 30-40% of all health care provided in the US is unnecessary, either by the approach of the patient being 'worried well' (overtreated), or the physician practicing 'defensive medicine.' A 2010 USA Today poll of 600 cardiologists revealed that nearly a quarter have ordered invasive heart operations only because they feared lawsuits. Think about the excessive costs with that.
Then, there's an extreme when over utilization becomes out of control. I've got a newspaper clipping around (can't find it) that found nine different people in Austin making nearly 3,000 trips to the ER over the span of just a year, at a cost of nearly $3million which was of course picked up by charity, the hospital, insurance and Medicaid. Eight of the nine people were found to have serious drug addiction issues. ER visits have gone up incredibly because of drug abuse; Rx drug abuse kills two people every hour, and sends 40 people to the ER every hour of every day. So there's good news and some not so good news
. Our ability to treat all these lifestyle diseases has gone up tremendously recently. For instance, the death rate from heart disease has gone down 50% since 1990. However, the cases still keep piling up. One of my favorite old sayings is that an ounce of prevention is worth a pound of cure, yet many people in the US view their own health like a credit card. Discussion of this topic without mentioning 'death panels' is impossible.
I know this is a common talking point among pro-privatized health proponents when talking about the ills of socialized healthcare in the UK. O noez! Not everybody can get the care they need when they need it? Answer is: NO.
This has absolutely nothing to do with which type of system you prefer, it has to do with the fact that no healthcare system will allow every single person to get every single procedure they want without imposing huge costs on the system. Remember that baby in Texas that was essentially born with no brain? The doctors said no way the kid was gonna live more than a few months without extensive and MASSIVELY expensive cost, yet the baby is cared for. Is incurring hundreds of thousands of dollars of cost to get a few extra weeks, maybe months, of life with no improved quality of life worth it? But more importantly, can we pay for something like that every time?
A friend of mine had that issue recently, his aunt had a terminal diagnosis of breast cancer and another, I forget which. They told them if they purchased a very amount of expensive care, they could increase her prognosis from six months to twelve, with no improved quality of life, she would be bed-ridden. They were faced with clearing out their family savings to do this. Again, I'm not making this a RTL issue, I'm asking: Can we afford to keep every single person alive for as long as possible every single time a terminal diagnosis is given? Prescription drugs
This one's a doozy. There's a couple things to look at.
Firstly, the US is the only developed country on Earth which does not have price controls for pharmaceuticals. On average, you'd pay fifty cents on the dollar for the same drugs you get here. The VA is the only organization in the US which is allowed to do this. Secondly, due to other factors, such as the US being only one of two developed nations on Earth which doesn't outlaw direct to consumer pharmaceutical advertisements, makes the retail cost of drugs not correlated to development costs.
I don't have the exact numbers in front of me, but when you spend $100 on a drug, $22 goes to profit margins (an extremely high rate) and $13 or $16 goes to marketing costs. More yet goes to highly paid reps and salespeople. Drug company execs have been on record saying they'd love to cut these costs, but the US drug industry is essentially an oligarchy, and to be the first to give up market voice or profit margins would be to run yourself out of business.
There's something that's not often discussed here, though: Generic counterparts. Nearly 80% of all drugs available in the US have a generic counterpart, yet due to a combination of marketing and old wives tales, many still think the name brand drugs are better than the generics. Still, these generic drugs, without the cost of R&D, can produce the drugs at such a cheaper price that drug companies often pay generic manufacturers to delay release of a drug past patent expiration. FDA and congress estimate this practice costs the American consumer 3.5billion per year.
The marketing machine doesn't stop there, unfortunately. Another common occurrence to happen lately is development of a new drug without any significant new areas of disease being covered; there is little or no R&D costs associated, but they can be heavily marketed and purchased because of marketing influence. This is wasteful spending. So, to review, why is health care so damn expensive?
- Poor personal health habits
- Aging baby boomers
- Technological innovations
- The uninsured
- Increased/irresponsible utilization
- Prescription drugs
- Resistance to any reform
We're not looking at a socialist system here. What we've got on the table at the moment is a system of complete participation, like they have in Switzerland. When you add the uninsured, nearly all of whom are above the poverty line (if they weren't, they'd be on Medicaid) into the insurance pool, costs go down for everyone. The people who need healthcare most are typically those least able to be able to pay for it, while the people who need it least are most able to pay for it. If a large portion of people are voluntarily uncovered by insurance, it drives up costs for the rest of us.
But as I mentioned it comes down to personal responsibility and choices. But individual choices are made within social contexts. Some serious rethinking needs to be done so we can get more people in a place to be making smarter decisions with their health.