Map of life expectancy at birth from Global Education Project.

Thursday, February 14, 2008

No Free Lunch

And no free pass for President Obama either. As you know if you've been reading -- because I mentioned it a few days ago -- Obama's health care proposals include requiring insurers to cover preventive services, which he claims will reduce health care costs. Hillary Clinton makes some vaguer claims along the same lines, to the effect that universal coverage will end up saving money because people will get timely preventive care.

Joshua Cohen and colleagues in NEJM consider this proposition. (And you'll be pleased to know that this is one of those articles of broad public interest that the editors have made available to the rabble, so go ahead and read it.)

Alas, as a general proposition it isn't so. Screening and prevention may be worthwhile, but that isn't the same as saving money. Very few procedures actually produce a net cost saving. Cohen et al don't point it out, because it isn't really the focus of their analysis, but the really bad news is that extending people's lives actually costs money. If somebody drops dead of a heart attack, you only have to pay for the funeral. But if they live for 20 years taking beta blockers and ACE inhibitors and statins and getting angioplasties etc., you've prevented a heart attack, but spent a helluva lot of money.

Population screening for relatively uncommon conditions is very expensive. It might or might not end up saving money for the individual who tests positive -- i.e., maybe it's cheaper to find breast cancer early than to find it later -- but any cost saving is likely to be offset by the cost of the screening itself, and by the cost of treating disease in people who otherwise might never have needed treatment, either because their disease was non-progressive (some lesions called "breast cancer" may be destined to just sit there and do no harm, ditto for prostate cancer), or the people would have died of something else first.

The bottom line is that the vast waste of resources in the U.S. health care system is not traceable to a failure to provide preventive care. That's the wrong diagnosis. The truth is, the main drivers of excess cost are the enormous administrative waste created by the private insurance system; the very high profits that accrue to pharmaceutical and medical device manufacturers, and the absurdly high incomes of some medical specialists; and doing too much, spending money on interventions that are useless, cost more than they are worth, or are actually harmful. The solution to those problems is:

Universal, comprehensive, single payer national health care.

End of story.

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