Health care realities

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Ah, the rites of spring! Baseball, cherry blossoms and the annual report of the Medicare trustees, who duly report that Medicare is going broke. Yet each year we have the routine response of politicians and pundits who wring their hands about the unsustainable rate of growth in health care expenditures.

Here's a typical comment: "Despite a massive increase in health expenditures together with a marked expansion in health workers over the past decade, the nation's health has improved less than expected. The benefits have not appeared to justify the costs. ... We have emphasized high-cost, hospital-based technologies " a situation " made all the more serious by the lack of emphasis on prevention of disease." Those observations were not made yesterday. They were made by Dr. John Knowles in a book titled "Doing Better and Feeling Worse: Health in the United States," published in 1975.

It is useful to look back to see far how we have come even as some things stay the same. In 1974, cardiovascular disease was the cause of 39 percent of all deaths. Today it is about 25 percent. Cerebrovascular diseases were responsible for 11 percent of deaths back then. In 2004 they caused 6.3 percent of deaths. Kidney diseases were linked to 10.4 percent of deaths and now they are associated with 1.8 percent.

Of course, the longer people live the more likely they are to die from cancer or Alzheimer's. The percentages of deaths attributed to influenza and pneumonia have remained almost constant, as have the percentages of people dying from respiratory diseases.

In general, however, more people regard themselves in good to excellent health now than about a decade ago. Fewer people have disabilities that limit their activity or require institutionalization. More people are getting screened and treated for chronic illnesses like depression, diabetes, high cholesterol and cancer. (Hypertension seems to be an outlier.)

The percentage of people unscreened and untreated for the disease has remained constant over the past five years.) We can thank spending on medical technologies that delay or prevent the emergence of disease for many of these gains. For anyone who thinks we can spend less on health care across the board and still have these benefits, consider that in 1974 many of the drugs and surgical techniques to keep heart patients alive were not available.

As Harvard University health economist David Cutler has noted: "The average person aged 45 will live three years longer than he used to solely because medical care for cardiovascular disease has improved. Virtually every study of medical innovation suggests that changes in the nature of medical care over time are clearly worth the cost."

Indeed, Medicare costs could be controlled by spending more on such technologies and by keeping people healthy. Mr. Cutler notes that "people 65 years and older, who have three or more chronic illnesses, spend 30 percent more on health care than those with none." He goes on to observe: "Medical spending in the last year of life falls from $32,000 for elderly who die young (ages 65-69) to half that amount for those who die above age 90. ... If we were able to keep people healthy until age 85 or 90, when people would then succumb to pneumonia or other less costly illnesses, one could envision ample savings in end-of-life costs."

All of this suggests that the way to reduce the rate of spending on health care was identified by Dr. Knowles more than 30 years ago. Since then, the shift toward prevention and detection has been salutary but insufficient. People are smoking less but are no more likely to exercise regularly than when Dr. Knowles wrote.

There are also more (even after accounting for those who pack on muscle) people who are severely obese. Too many people still remain unscreened for the chronic illnesses that cost so much to treat. We have not done enough to replace more expensive and invasive forms of acute care with approaches that are less expensive and time-consuming (like prescription drugs).

Too often we go to the wrong place for care and wait too long before receiving it. In particular, emergency rooms (ERs) are still full of people with scrapes, ear infections, panic attacks and breathing problems which could be taken care of in less-expensive settings. (Rates of admission to ER s are no different, whether one has insurance or not.)

As the genetic variations that predict our risk of disease and response to treatment are translated into tests and treatment, the waste from trial and error or unproductive intervention will fall as well. But there is a lot we can do without much effort to save money and improve health. More prevention, shifting care to lower-cost settings and rewarding people for healthier living can move us forward. That's not a crisis; that's an opportunity.

Robert Goldberg is vice president of the Center for Medicine in the Public Interest.