Human Limits

It has been a while since I did a post on big picture issues related to health care in the U.S. In the last couple of months several ideas or perhaps rescue fantasies have emerged or perhaps re-emerged and I want to go over them.

1)  Lack of Price Transparency

In the U.S. prices for various medical procedures are convoluted, idiosyncratic and extremely hard for even the experts to understand.   A recent NY Times article on the costs of having a baby in the U.S. highlights many of these issues.   Because there is no obvious rack rate and prices are not posted by most medical providers, some employers are essentially capping what they will pay for a given procedure or service.   Along these lines, my bet is that there is going to be a big price transparency movement, more so-called bundled payments, and that the regulators will play a role in this.   The important thing to remember is that what people and insurance plans actually pay typically has little relationship to what the list price is if you can find it.   The other point here is that even if prices are more transparent it might not do that much to lower overall medical care costs which are driven in large part by utilization of services.  I am all for more transparency, but it is not going to solve the cost problem.  It is also interesting to note the late physician turned science fiction writer Michael Crichton raised many of these issues in a long article in the Atlantic published in 1970!

2)  Rising Costs: a Problem Everywhere

The next point I want to make is that rising prices are a problem in almost all rich countries and a number of developing countries.   Many of these countries have strict price controls and essentially government run programs.  So thinking that there is some magical intervention “the government” can or should do to fix the problem is simplistic at best.  My bet is that Obamacare will struggle to contain costs.  The real drivers of rising costs are likely the aging population and advances in technology.

3)  The Recent Slowing of Health Care Spending Growth

The rate of growth of health care spending has slowed recently.   If this trend continues it has all sorts of implications for things like the U.S. Federal budget.  However, I would urge caution in assuming that this trend will last forever.   In past economic slowdowns there has also been a slowing of medical care spending growth followed by a rebound when the economy picked up.  As I pointed out above no government in the developed world has effectively dealt with this issue over the long run, the population is still aging, and technology marches on.

4)  Denial & Practice Variation

The current focus on price transparency and the recent slowing of spending growth are major distractions away from at least one major issue that might tend to reduce the rise in spending over time.  That issue is the tremendous regional variation in the use of health care services in the U.S. and the lack of relationship between a number of markers of utilization and outcomes.  Some argue that 30% of Medicare spending does not contribute to improved patient outcomes and is thus “wasted”.  The figure below is a bit dated but still relevant and generally accurate.  It shows a range of estimated savings for Medicare if all 50 States had utilization rates and practice patterns similar to the five most efficient States.  Numbers in these general ranges likely apply to health care spending as a whole.

There are a number of ideas out there about how to deal with this issue, but they are likely to be challenging to implement.

5)  Rent Seeking & Why This is Hard to Fix

Almost 18% percent of the GDP is spent on health care in the U.S.  Almost 50% of this spending comes from the government in terms of either programs like Medicare or Medicaid, the VA, or Indian Health Service.  Additional government spending is due to insurance provided to government workers at the Federal, State, and Local levels.   There are also significant government subsidies for health care spending via the tax code.  So, in one form or another “the government” probably covers 60-70% of medical costs in the U.S.  As a result there is a huge and diverse group of vested interests angling for either maintaining or expanding their piece of this economic pie via what might be characterized as ‘rent seeking’ behavior:

“…..rent-seeking is an attempt to obtain economic rent by manipulating the social or political environment in which economic activities occur……”

Summary

Dealing with the high cost of health care in the U.S. is going to take more than price transparency and don’t bet the farm that current moderation of rising costs is going to last forever.   The 800 pound Gorilla in the basement is utilization which, given the aging population, ever more technology, and economic incentives to over utilize, will be very difficult to contain. 

After the post on Alain Mimoun I got a nice note from publishing icon and fitness activist George Hirsch:

“Thanks for this. As a teenager, I attended the 1952 Helsinki Games and became a lifelong admirer of Mimoun, a true champion in every way.”

That led to a longer exchange about George’s role as a leader of the NY Marathon in bringing Mimoun’s great competitive partner Emil Zatopek to New York in 1979.  The picture below is of Bill Rogers, George and Zatopek out for a run in Central Park.

As e-mail conversations sometimes do, things drifted to Zatopek’s support for greater political freedom as part of the Prague Spring in 1968.  With the suppression of the Prague Spring, Zatopek lost his official status and was apparently given a series of menial jobs.  At some level he was probably protected from even more harsh treatment by his international status and George Hirsch indicated that it did not take a major diplomatic effort to get him to New York in 1979.  In 1990 he was politically “rehabilitated” as communism crumbled in the former Czechoslovakia.   So, like Mimoun, Zatopek was a man of great personal resilience.

How Does This Relate to Nelson Mandela?

All of this discussion about resilience got me thinking about Nelson Mandela whose health and perhaps life is slipping away at age 94.  The details of Mandela’s life are well known, but perhaps less well known is that he was devoted to a program of calisthenics and running in place during his nearly three decades as a political prisoner.   In his 70s he then had the physical stamina to emerge from prison, lead his country and focus on reconciliation vs. revenge.  He also continued an exercise program well into his 80s.  I can’t help but think that his physical endurance contributed to his mental endurance and the resilience it took to just keep pushing forward against long odds.  From a scientific perspective surely the exercise helped him deal with the stresses of resistance and leadership and kept him cognitively sharp for a long time.

The 4^th of July is a time when we should all spend a few minutes reflecting about the ongoing struggle for human freedom.  Thinking about how Nelson Mandela pressed on over so many years is a good place to start, and so is following his example and getting some exercise before the festivities and fireworks start.  At some level resilience is a skill that can be learned and physical activity can surely contribute to it.

The great French/Algerian runner Alain Mimoun, who won the marathon at the 1956 Olympics, died last week at the age of 92.  Mimoun is best known for his many silver medal finishes to the incomparable Emil Zatopek who is arguably the greatest distance runner of all time.  Less well appreciated is that Mimoun is in many ways a herald of all that came after him:

• He was born in Algeria when it was still a French Colony.  This is what we now might call the developing world and his excellence anticipated by more than a decade what other North African Arabs and runners from Ethiopia and Kenya have achieved starting with Abebe Bikila in 1960.
• He competed well for a very long time in an era when careers at the highest level typically lasted for only a few years.  In 1960 he competed in his fourth Olympics and placed 34^th in the marathon with a time of 2:31:20 at age 39.
• He won the French national title in 1966 at age 45 and in his early 50s he broke 2:35.
• He remained fit and active into his 90s.

I knew about his races with Zatopek and his victory in 1956 from the Bud Greenspan documentary “The Persistent Ones”, but I had no idea that he was one of the first great master athletes as well and a model for successful aging.  The video below shows Mimoun running in the forest at about age 90.  He was clearly a man ahead of his time and an example for us all.

click here for video