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.