The Muddled Debate about America's Medical Crisis: Or Why Overuse of Medical Care Is Not the Cause by Professor Theodore Marmor and Kip Sullivan
Over the past half-century, Americans have repeatedly expressed support in opinion polls for universal health insurance to protect citizens from the devastating costs of illness. They have favored as well public financing of universal coverage plans without complex deductibles, benefit limits, or severe restrictions on their physicians. At the same time, many Americans have been repeatedly scared into thinking that universal health insurance is unaffordable. Americans, we have been told for decades, overuse medical care and such "overuse" would only worsen if all Americans were insured.
Now that health care reform, to judge from recent attention in newspapers and other media, is back on the nation's agenda, we will hear the same contentions of excessive use. The argument for universal coverage -- citing health inflation and declining insurance coverage -- will prompt the familiar skepticism about affordability. (The current rate of inflation in health care -- 5 percent per year -- is twice that of general prices, and health insurance premiums are increasing at double-digit rates.)
The 2003 debate about affordable reform, unfortunately, is likely to be as muddled as it was a decade ago, when President Clinton promoted universal health insurance under the banner of managed care and the inflation rate in health insurance premiums was also in double digits.
Now as then, those with interests in rising health expenditures will try to make sure the American public does not understand the real causes of the recent surge in medical inflation. Call the protagonists the "medical-commercial" complex on the one hand and the universal health insurance advocates on the other. In the middle are the communicators, the writers, producers, and reporters who, in presenting the melange of arguments, bewilder the public.
According to proponents of the overuse argument, the American appetite for medical care really explains our chronic inflation problem and makes reform unrealistic. Last summer was a preview of what is to come. On Aug. 15, for example, CBS news reporter, Carl Mercurio, repeated the overuse theme cliche by cliche. "As Americans, we want the best health care in the world and we want unlimited access to health care and we don't want to pay for it." In the Aug. 21 edition of USA Today, a senior economist at UCLA's Anderson Forecast was quoted as saying, "the people to blame in the end, the ones ultimately responsible, are consumers. People don't adequately take into account the true costs of the services they're consuming." In July, a Blue Cross executive expressed delight at the attention to overuse, claiming that the solution to health inflation is to "curb America's appetite for care."
This is neither new nor likely to stop. Since the l970s, those groups whose members draw their incomes from health expenditures have regularly alleged that American patients overuse medical care. The Jackson Hole Group, the coalition of medical and business executives that took its name from the Wyoming resort town where the group met, was the best known illustration. Their answer to medical overuse and persistent inflation was the health maintenance organization, the label for managed care. Greedy doctors overproviding expensive and often questionable services were the primary targets for HMOs to reform.
Now that managed care has proven unable to contain medical inflation, some business groups have made patients the abusive users. The Wye River Group, named after a Maryland resort for corporate retreats, claims that "overinsured" patients are the culprits. Their solution is to expose Americans to health insurance with huge deductibles -- $3,000 to $4,000 annually per family. These newly fashionable, large deductible policies go by a variety of names, the most common of which are "defined contribution plans" and "medical savings accounts." From the puzzling jargon about savings accounts, and contributions, to the overuse diagnosis the barriers to public understanding are considerable. What is the average citizen to make of all this?
Does overuse of American medicine exist, and, if so, is it a primary reason for the explosive inflation we are now experiencing? Overuse does exist, the evidence indicates. But so does worrisome underuse.
In any case, overuse cannot possibly explain either the latest burst in health insurance prices or the sharp rises in what drugstores, doctors, and doctors charge. There is no credible evidence that Americans received a lot more medical care in the past few years. But the prices of health care service and products surely skyrocketed.
The evidence also shows that America's inflated prices in medical care contribute much more to our high level of health expenditures -- 14 percent of national income -- than the net of overuse minus underuse. This points not to the overusing patient, but to the economic power of our insurance administrators, pharmaceutical firms, hospitals, and consultants. Hospitals with an excess of beds want revenues to finance them; administrators, consultants, and drug firms regard high expenditures on them as desirable income, not wasteful medical expenses. We should not expect these parties to treat increases in their incomes as the cause of our medical troubles. But that does not mean we should believe their accounts of our medical inflation either.
Overuse of antibiotics is probably the best-known example of excessive use of medical care. There are few attentive Americans who have not heard that new bacterial infections, resistant to treatment, have become a danger because of reliance on antibiotics for minor ailments. Other examples are the numbers of MRI machines and extraordinary proportion of American women who receive epidurals when giving birth to their children.
The examples of underuse are equally numerous, however. Consider the following:
+ Two-thirds of all Americans with mental disorders do not seek treatment;
+ Half of all insured Americans suffering from high blood pressure are not getting treated;
+ Half of insured patients who, according to a stress test, should have an angiogram do not get it;
+ A third of the nation's diabetics do not know they have diabetes;
+ One fifth of those with disabilities who have a prescription fail to take their drugs as prescribed; and
+ One-eighth of the insured nonelderly does not fill a prescription because of cost.
Advocates of medical savings accounts and other high-deductible plans turn to talk of overuse because they think they have an answer to it. With a few exceptions these advocates avoid discussion of underuse. They know they have no solution for underuse and that their practices will almost surely aggravate it. But that does not dissuade them from disseminating the overuse thesis at the meetings of health insurers and the gatherings of groups like the Chamber of Commerce and the National Association of Manufacturers. The familiar critics of universal health insurance find the overuse argument a settled matter.
In that context, a sensible discussion of medical inflation, let alone universal health insurance, is very difficult. It is almost impossible when the media act like an echo chamber, amplifying the voices of the already heard. Well-financed interest groups have lobbyists who are paid and prodded to comment and who show up regularly in debates that journalists try to "balance." The trouble is that there are 50 industry spokespeople for every under-financed representative of ordinary citizens. The news all too often then turns out to be what prominent figures in the medical-commercial complex claim. No wonder then that Americans support the reform principles of universal coverage but express fear at most efforts to act on them.
Theodore Marmor is a professor of public policy in the Yale School of Management. Kip Sullivan is a lawyer and writer on medical care topics in Minnesota.