Ezekiel Emanuel, pondering our fate

What is missing from our health care debate—even as conducted by our most insightful and radical critics of the dysfunctional American health care system—is a recognition of what, underneath it all, drives the system.  It is Americans' insatiable lust for health care.  What Americans possess in overwhelming abundance is the urge to be treated for their maladies.  Witness our massive formal addiction and mental health disease treatment and support system (as opposed to the informal community supports offered more readily around the world).  And our most forward-thinking health care advocates can only imagine expanding this system exponentially (e.g., parity in health care coverage between physical and emotional illness).

American health care costs are driving America into the ground.  These costs stand at from 2-3:1 compared with other nations (like the UK), and the chasm is widening since virtually all other nations have stablized these costs, while we are only beginning to tackle the rate at which they increase.  But Republicans can still run on simply resuming lock, stock and barrel the same old private care system, Americans in general dislike Obamacare, and Obamacare itself is built primarily around expanding coverage without controlling costs.  This is because any effort to rein in such costs is met by accusations like "death panels" or "rationing," which immediately kills them like glassy-eyed dead fish floating on the surface of the stagnant pond that is our care system.

It does no good to cite comparisons between America and other countries, like the study finding mature adult Americans in all social classes to have twice the rate of virtually every type of illness (from cancer, to heart disease, to diabetes) as the English, despite that the latter smoke and drink more (they are thinner), and that the British system spent (at the time of the study; the gap is greater now) roughly one-half of what Americans do per capita on health care.1  And the gap between our health outcomes, on the one hand, and our costs, on the other, are growing rapidly relative to the rest of the world.2

What Americans like about Obamacare are provisions that guarantee more access to health care for themselves and their children.  Fair enough (other Western countries provide easier medical access for basic care than Americans have with more doctors, health care facilities, and lower—often negligible—barriers and costs).  What they dislike is any suggestion that Americans might have to curb their appetites for more, more, more health care.

An amusing demonstration of this fear and loathing by Americans is represented by their reactions to recommendations from the U.S. Preventive Services Task Force, most recently concerning the inadvisability of routine screening for prostrate cancer and annual mammograms for women under 50.  Both these recommendations were made without cost calculations (obviously useless tests and procedures are expensive), but solely based on the wayward outcomes of routine screenings due to inevitable misinterpretations of the tests, the resulting unnecessary provision of care and damages due to these interventions, and net bottom lines that people do better without such screening.

The issuance of any such recommendation is met with howls of disapproval by not only interest groups that urge and profit from such testing, but from men and women who swear it saved their lives—medical-epidemiological research be damned.  And we are all swayed by such arguments.  Witness the recent discussion on MSNBC's Morning Joe where health care reform advocate, former Obama adviser, and professor of oncology and health ethics at the University of Pennsylvania, Ezekiel Emanuel, discussed the panel's declaring routine prostate testing inadvisable.  Not only did Joe Scarborough and the rest of the men around the table reject the recommendation, but Emanuel himself "confessed" to having gotten such a test, claiming he did so only because his doctor insisted (such a will-o'-the wisp Emanuel is, blowing in the wind!).

Americans feel better going to doctors and receiving health care—like people feel better when taking certain potions and engaging in certain activities—even if, as a result, they suffer worse outcomes.  This is addiction. And the British, among others, suffer less overall from feeling this way towards health care (it is not a struggle to convince them to avoid tests and procedures that have been found to lead to net negative consequences), even if they engage more in addictions like smoking and drinking!

So who are the worst addicts, us or those smoking, drinking Europeans, as health care costs rise unceasingly, drive our economy and competitiveness into the ground, and cause our national political debate to grind to a halt, since we are unable to create a unified national health care system that would actually enhance our lives and increase our life spans?  And, let's face it, such a universal health care system would provide more necessary care but less overall care than the best-insured of us are used to and would tolerate.

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1. "The US population in late middle age is less healthy than the equivalent British population for diabetes, hypertension, heart disease, myocardial infarction, stroke, lung disease, and cancer. . . . This conclusion is generally robust to control for a standard set of behavioral risk factors, including smoking, overweight, obesity, and alcohol drinking, which explain very little of these health differences. These differences between countries are not due to biases in self-reported disease because biological markers of disease exhibit exactly the same patterns. To illustrate, among those aged 55 to 64 years, diabetes prevalence is twice as high in the United States and only one fifth of this difference can be explained by a common set of risk factors." In other words, usual health outcome predictive models are almost useless for explaining these differences. Banks, J., et al. Disease and disadvantage in the United States and in England, JAMA 2006;295(17):2037-2045.

 2. "In the 1950s, the United States, having among the lowest mortality and other indicators of good health, ranked well among nations. Since then, the United States has not seen the scale of improvements in health outcomes enjoyed by most other developed countries, despite spending increasing amounts of its economy on health care services." Bezruchka, S. The hurrider I go the behinder I get: The deteriorating international ranking of U.S. health status, Annual Review of Public Health 2012;33:157-173.


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