When a fantasy of higher health quality meets reality

I’ve long thought, and often said, that to have good health is one’s most important asset. Do you agree with me? I bet most do.

Yet health in America is not good. Across many measures and relative to our peer nations the quality of the US health system is, at best, mediocre. Sure, we’ve got a top notch system in certain, narrow ways. But broadly, we have a lot of work to do.

Sometimes I fantasize about another world, one in which this is not the case. Imagine the US had the best health system, across a wide range of objective measures of quality and population health. Imagine we could support the statement that the US was number one in health. Imagine it was indisputable, common knowledge.

But imagine also that our health spending was also as it is today, much higher than that of any other nation, even controlling for wealth. Finally, imagine we faced high and rising debt due to high and rising health spending, just as we do today. How would the debate about what to do be different in this imaginary world than the one we experience in our reality?

In that imaginary world, I think the argument to keep spending more and more on health care would be more compelling.The argument for raising more tax revenue to keep pace with public health spending would be easier to make. All one would have to say to someone who wanted to cut back is that we owe our world-leading longevity, our record low infant mortality, and our supremely more healthy lives to our level of health spending. One could argue more credibly that as the nation becomes wealthier we should spend more of our wealth on health care because it works, it is money well spent. Note, I’m not saying that this argument need be a correct one. But one could at least make it if we had the best health outcomes in the world.

We cannot make that argument now because we don’t have the world’s best health system. Far from it. Therefore, it is very easy for many to say we’re wasting a lot of money on health care. That’s very credible. I believe it. I also believe that simply cutting spending will not do a thing for increasing quality. It’s just not that simple.

The debate over health care is disproportionately focused on spending, that it is too high and growing too rapidly. At the same time, reducing spending on health is very hard, due to political and economic factors. Increasing the quality of health care and improving population outcomes is no easy feat either. Still, it is worth asking, should we be exerting more effort trying to do so? If we did, and if we succeeded, the spending would be more easily justified, would it not?

Increasing quality, or how to do so, is not without controversy either. Comparative effectiveness or, related, patient-centered outcomes research is not universally accepted as the way forward. Pay for performance demonstrations don’t have an undeniably and consistently stellar record. A lot of what drives poor health outcomes may have nothing to do with our health system directly and more to do with how we eat and live. Do you think Americans will easily accept messages to change their lifestyles? Even if they do, interested industries won’t. Finally, it might take even more money than we spend now to improve population health. It probably requires spending on things other than the health system, like education and investments that lead to greater and more widely shared income and wealth. It probably requires more income redistribution.

So, don’t get me wrong, achieving high quality and better population health is a hard problem. But I wonder if it would be a more accepted goal than is reducing spending. In other words, what if we forget about health spending, for the moment, and just focus on health and well-being, and how to improve them broadly. I admit, it sounds foolishly idealistic to me. But so does gaining “control” over health spending.

Given a choice, I’d rather have lower health spending and superb health. Today we have the worst of both worlds. It’s a great luxury to be so spendthrift. We have claimed that luxury as a legitimate exercise of freedom. If that is our right, do we deserve it? If you say that we do, what is the moral basis of your argument? If you agree with me that health is paramount why is it not a more protected right?

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