My earliest memory of visiting a doctor was created when I was four years old. I had a wart on my index finger, which made it hard to properly hold a pencil. My dad drove me to a medical office, where an avuncular physician made a quick examination, left the room, and came back with a small bowl from which a thick white fog issued. I don’t recall whether he said “Abracadabra” as he applied the solution to my finger, but he may as well have. The wart magically disappeared before my eyes.
The experience taught me that medicine was mystical, a feeling that was reinforced by the Readers Digest articles I read when I visited my grandparents. In them, evil diseases such as polio were defeated by compassionate giants like Jonas Salk, who were destined to conquer even more villainess oddities, like Elephantiasis and Dengue Fever. Regular doses of “I am Joe’s Lung” and other stories describing the inner workings of a myriad of organs, as if they were separate beings capable of speaking for themselves, made the body seem like an enchanted forest expertly tended to by wizards.
Twenty years later, fresh out of graduate school in public policy, I landed a position at the U.S. Office of Management and Budget (OMB), which develops the federal budget. My job was to find ways to reduce expenditures on the massive Medicare program, which at the time cost almost $40 billion a year, more than one percent of gross domestic product (GDP).
Providing health care to the elderly is immensely popular. However, there’s ample evidence that government subsidies have stoked the creation of a medical-industrial complex – MIC, for short – that’s motivated as much by cash as delivering care. Plus, as one of my bosses pointed-out, for multiple Americans Medicare serves mostly to protect inheritances. Roughly one-quarter of Medicare spending is for services given in a recipient’s last year of life. In many medically-prolonged deathbed cases Medicare has the effect of transferring the burden of paying for arguably unnecessary and even cruel interventions from heirs to taxpayers.
In the face of the substantial odds against it – a handful of eager twenty-something analysts who aren’t as smart as they think they are versus a multi-billion dollar industry – OMB practices what amounts to a “Mother May I” approach to managing federal health care spending. For long time periods the government essentially covers its eyes as MIC chows down on federal checks. From 1980 to 1990 Medicare expenditures tripled, to roughly $120 billion. Then, after much political wrangling, new reimbursement regulations are adopted, for example, paying a set amount for a given hospital procedure.
The rule change might momentarily slow MIC’s chewing, but ultimately the beast figures things out, and returns to its gluttony. By 2000 Medicare spending had reached about $200 billion. OMB’s efforts are akin to heading buffalo. Whack them on their hindquarters and they don’t budge much, though sometimes if you rush at them with enough horsepower you can get the animals to stampede in a slightly different direction.
Despite MIC, medicine continues to be enchanting. My 80-something father-in-law, Fred, almost felled from a failed heart, was brought back to life by an accessible University of Michigan cardiologist. The procedure gave him upwards of ten more years. But the magic comes at a price that’s more than the costly bill someone must ultimately pay: it often requires a level of persistent and sophisticated advocacy that’s beyond most families. It took weeks, intensive lobbying, and good connections to get Fred the right care. Almost everyone who has had to grapple with MIC over a complex health care challenge comes away with the same story: securing the right doctor, to make the right diagnosis, and implement an effective treatment can be almost as difficult as the medical condition that needs to be addressed.
The adage that everyone likes their congressperson but no one likes Congress could be applied to our health care system. Hospitals and clinics are overwhelmingly staffed by compassionate professionals who are dedicated to helping their patients. But they operate within a much less friendly structure that has a goal, like many other American institutions, to maximize wealth and/or prestige. And, as with other institutions, MIC has a limited ability, or perhaps even desire, to handle diversity and wholeness. As 80-something Potrero Hill resident Margaret Keyes stated, of her cascading set of medical challenges, aging requires a “…tackling of the medical clots of deterioration, rather than treatment of individual diseases as such.” Said differently, MIC is as good as the codes Medicare and other insurers allow it to bill against when it provides its services. Care is a multiple choice test, not an essay, with the goal of getting the highest financial score.
In 2014 Medicare expenditures reached almost $600 billion, equal to roughly three percent of GDP, a 15-fold increase since when I worked for OMB. No doubt this spending has purchased a large number of miracles, bringing back the dead, reducing suffering. But we’re paying too much for too little, and working too hard for the care we receive. Life expectancy increases over the past thirty years, for instance, have been modest, rising from 74 in 1980 to 79 today, and may be more attributable to improved lifestyles than medical interventions.
Medicine may be magical, but delivering it is big business. The real miracle would be to continue to foster the former while reducing the burden associated with the latter.