Healthy, Wealthy, or Wise? Issues in American Health Care Policy

By Charles T. Stewart Jr. | Go to book overview

Diminishing returns from further investments in treatment and prevention suggest diminishing returns from additional research and development as well, until there are major breakthroughs in treating remaining major sources of morbidity and mortality. Mortality is already so low until age sixty, with the exception of AIDS, that remaining gains are bound to be limited until such time as means are found to extend the useful life span, as distinguished from treating the conditions and illnesses of the aged. No one knows when such breakthroughs temporarily reversing the inexorable trend of diminishing returns will occur, nor how much in research they will cost. Until then, increasing expenditures for medical care cannot be justified in terms of health benefits and risks, never mind the economic costs of health gains. The costs are not just money, they are other desiderata foregone.

* * *

There is no single, simple solution. What is needed if the share of GNP devoted to health care is to fall to more reasonable levels, and be kept there, is a combination of a large reduction in the number of medical personnel and facilities; a list of services for which there is no insurance coverage, plus price ceilings on services that are covered; a shift of incentives away from overprovision of services toward limiting them to instances of medical need and worth; and, perhaps, an overall spending ceiling, to limit the quantity of covered services provided. The latter spending ceiling requires reorganization of the delivery of medical care. It can be applied to HMOs and similar systems of prepaid delivery of health care that have an incentive to restrain spending. It can be imposed on hospitals, by generalizing Medicare's DRG system, with payment depending on the diagnostic classification. It is not workable in fee-for-service health care delivery.

How can all of this come about? There must be a profound change in attitudes toward individual rights. No individual has the right to empty another's pocket; but that is precisely what is widely believed, and often practiced: theft by another name. Rights to health care are social, not individual, and must be defined by a process of consensus. This is what we do in signing an insurance contract of any kind, or joining an HMO; the signer has limited rights: to specific services, under specific conditions, to limited amounts. The citizen pays taxes not of his choice, receives benefits also not as he chooses, but as the body politic specifies. The rights of any individual are limited by the rights of others. Health care is no exception.


Notes
1.
Richard Lamm, "What It Will Take to Really Control Health Care Costs," Medical Economics, July 20, 1992, 81-89.

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Healthy, Wealthy, or Wise? Issues in American Health Care Policy
Table of contents

Table of contents

  • Title Page iii
  • Contents v
  • Preface vii
  • Notes viii
  • 1 - Determinants of Health 1
  • Notes 6
  • 2 - Why Are Costs Out of Control? 7
  • Notes 27
  • 3 - Must Living Standards Decline? 28
  • Notes 38
  • 4 - Health Insurance Raises Demand and Supply 40
  • Notes 49
  • 5 - The Excess of Physicians and Services 51
  • Notes 77
  • 6 - The Medicalization of Health 82
  • Notes 97
  • 7 - Mental Illness 99
  • Notes 119
  • 8 - The Excessive Demand for Medical Care 123
  • Notes 136
  • 9 - Research and Technology 138
  • Notes 161
  • 10 - The Physician as Agent 164
  • Notes 179
  • 11 - Prevention: Environmental and Behavioral Modification 181
  • Notes 210
  • 12 - The Demedicalization of Health Care 213
  • Notes 222
  • 13 - What to Do? 223
  • Notes 250
  • Index 253
  • About the Author 263
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