This has to stop somewhere

Banthin and Bernard, in the new JAMA (abstract here, but you'll have to wait for your faculty appointment to read the whole thing) used data from the Medical Expenditure Panel Survey -- an ongoing project of the Agency for Healthcare Research and Quality -- to track changes from 1996 to 2003 in the percentage of the population under age 65 who are heavily burdened by health care expenditures.

Their method estimates that in 2003, 48 mllion Americans under age 65, 19.2% of all of us who haven't made it to Medicare, lived in families spending more than 10% of their income on health care, and 7.3% in families spending more than 20% of their income. Those numbers may or may not appall you, but what is most important is the very rapid increase in these proportions. In 1996, 15.8% of people lived in families spending 10% or more on health care, with 5.5% spending more than 20%.

The risk is obviously much higher for people with chronic diseases such as diabetes or severe mental disorders, and it is also higher for poor people, including Medicaid and SCHIP beneficiaries, who are spending more and more out of pocket. Indeed, people with private insurance are also spending more out of pocket, and 5.5% of people with private insurance spent more than 10% of their income on out-of-pocket expenses. This means, obviously, that they are likely to forego services that might be needed, and help prevent more serious problems down the road.

Note that if these trends continue at the same rate -- and in fact there is every eason to believe they have been accelerating -- we'll have almost a quarter of the population under age 65 spending more than 10% of family income on health care, and 8.3% spending more than 20%. Since the real wages of American workers have been stagnant for many years, this is coming out of food, housing, education, retirement saving, and other basic needs for most people who already do not have a lot of disposable income.

The burden on society of Medicare is growing even faster, but this adds important context to the debate over what to do about the future of Medicare. In order to finance benefits for elderly people in the future, the workforce will have to be able to make a larger contribution than it does now. But with workers' income also being eroded by health care expenditures, that isn't going to be easy.

As a society, we are just going to have to override the special interests -- drug and insurance companies, the AMA, and others -- who stand in the way of real reform. We are going to have to join the ranks of civilized countries that have structures in place that enable them to get control of this problem. The longer we wait, the worse it will get. There just isn't any choice.