I recently read Who Shall Live?, written in 1974 by Victor Fuchs, professor emeritus of health care policy at Stanford Medical School. This month's column summarizes the book's major findings, including some interesting quotes.
As you read the following, ask yourself whether or not our health care system has evolved since then. And if not, why not?
We faced a health care crisis in 1974, as exemplified by:
- health insurance rates doubling every 10 years;
- high number of medically uninsured;
- lack of easy access to care; and
- personal bankruptcies due to medical bills.
"In recent years, almost every American family has become acutely aware of the soaring costs of medical care ... the U.S. health care system is in crisis," wrote Fuchs in 1974. At the time, health care cost about $450 per person annually - 8% of GDP, double the rate of 20 years earlier. Costs had risen about 10% annually for a decade.
We spent more on medical care than did any other country. But our outcomes, as measured by life expectancy and infant mortality, were mediocre. Our infant mortality rate in 1970, for example, was about one-third higher than in Scandinavian countries or the Netherlands. Today, the ratio is about the same.
Our life expectancy rates were similarly poor. Yes, we lived longer than Americans of a generation earlier - but not as long as people in other countries. On average, an American's life expectancy was about 71 years in 1970. Britons lived 72 years, Canadians 73, Dutch 74 and Swedes 75. This, despite our spending far more on health care than any of those countries.
Today, we rank about 40th internationally in life expectancy.
Fuchs attributed our high spending and poor outcomes to the dichotomy between public health activities and private medical care. Easy, inexpensive public-type investments generated the greatest gains.
For example, infant mortality rates fell in this country by about 90% from 1900 to 1970 due primarily to higher living standards, improved sanitation, availability of antibiotics and better birth control - but not due to improved clinical care.
Meanwhile, expensive medical treatments involving the latest, greatest technologies "do not have much effect" on driving down infant mortality rates, although clearly they greatly affected a small number of people. The same seems true today.
The leading causes of death in 1970 were heart disease, cancer and stroke - largely behaviorally based diseases. These are the same leading causes of death we see today. Interestingly, since 1970 diabetes has replaced cirrhosis of the liver as a leading cause of death. Perhaps as a nation, we're now eating more junk food but drinking less alcohol.
How prescient Fuchs was in 1974 to see that higher income levels and related lifestyle changes in diet, exercise, smoking and driving would do as much harm as good for our individual health.
Fuchs saw little correlation between medical spending and health, claiming that "it is the patient rather than the physician who has the major influence on his health." Health is more dependent on personal behavior - that is, lifestyle - than it is on medical care, he asserted.
Sound familiar? Here's a comment made in 2009 by former Senate Majority Leader (and cardiologist) Bill Frist:
Health is not health services. Health is behavior, it's genetics, it's socio-economic status, it's disparity, it's environment. Health services has about a 15%-20% impact. (Source: CNBC program "Meeting of the Minds," July 2009.)
The commonly discussed cost-control proposals in the "emotion-laden debate" of 1974 included:
- National health insurance to cover everyone and reduce administrative costs and waste.
- Better preventive care, including living healthier lifestyles.
- Increasing patient's cost-consciousness by making them pay substantial deductibles and coinsurance.
- Altering provider incentives to control costs.
Sounds similar to the proposals being bandied about today, doesn't it? This should give us pause.
Since 1974, our health care expenditures have roughly doubled as a percent of GDP. We still outspend all other countries on health care. We still rank poorly on international longevity and infant mortality scales. We still have millions of uninsured.
And we still look to our medical system to fix the harm we cause ourselves from unhealthy lifestyles.
Sometimes reading a book or commentary from years ago helps put today's issues in historical context. It may make us feel good to see how we've advanced as a society. Or feel depressed to see how little progress we've actually made. EBA
This month's column is related to "Insurance Solutions to Healthcare Problems," approved for CE in most states. EBA readers get a 15% discount on it through March 31, 2010. To access your discount, visit HealthInsuranceCE.com and use code "EBA-Feb" (Florida brokers use "EBA-FebFL").
Fradin is the president of HealthInsuranceCE, a provider of continuing education courses for health insurance brokers. He is also the author of Moral Hazard in American Healthcare (2007) and Healthcare Problems and Solutions (2008).
