Medical Bills and the Price of Miracles


January 06, 1993|By DANIEL S. GREENBERG

Washington -- America's soaring medical bills have bee designated economic enemy No. 1 on Bill Clinton's reform agenda. They're eating up money needed for industrial rejuvenation and other worthy purposes, the president-elect says. And rising costs, he adds, are pricing too many people out of the health-care market.

But the incoming administration faces an awesome, perhaps impossible, task in trying to control the economics of the health-care system. Savings are surely possible and must be pursued, but they're greatly overshadowed by forces for even greater spending.

The reason is that health-care American style got the way it is because it satisfies many of the needs and rouses the hopes of a great majority of Americans. They revere high-tech medicine, an abundance of well-trained doctors and other health workers, and a world-leading biomedical-research enterprise that's forever promising miracles and, in fact, now and then delivers.

Reformers insist that more could be done for less if needless services were eliminated, and if the great multiplicity of health-insurance agencies, government and private, were consolidated into a single-payer system with minimal, uniform paperwork requirements.

With the health-care industry running at $838 billion a year, claiming one dollar out of every seven spent in the U.S. economy -- and rising rapidly -- there's no doubt that savings can be achieved. But the opportunities for holding down costs are more than matched by the surge of wondrous, and expensive, technologies and drugs gushing forth from the labs of medical science.

Some medical innovations, such as vaccines against polio and other diseases, are extremely cost-effective, i.e., small expenditures prevent diseases that require costly care,

sometimes over a lifetime. But many of the new technologies now in use or soon to be are enormously expensive and have the potential for evoking wide demand.

For example, research is rapidly proceeding on development of a fully implantable, mechanical heart, expected to be ready for experimental trials in about a decade. According to a study by the National Academy of Sciences, the cost per unit will be $150,000 to $200,000, and the patient load is estimated at 200,000 by the year 2020. Meanwhile, temporary mechanical-heart replacements, known as ventricular-assist devices, are already in experimental use to sustain patients waiting for human-heart transplants.

After these devices are refined, as they inevitably will be, they will join hip replacements, coronary-bypass surgery and other medical wonders that have become commonplace items in the armory of modern medicine. For government to restrain their use on the grounds of cost might make economic sense, but the political costs of saying no are likely to be high.

Though Mr. Clinton has not yet provided the fine details of his health-reform strategy, two of his basic ingredients collide with America's yearnings for an abundance of only the best in health care. These are firm ceilings on national health spending and managed competition among large health-service providers, such as health-maintenance organizations.

According to the health-policy thinkers around the president-elect, the two concepts in combination will restrain cost increases, thus making it affordable to provide coverage for the estimated 35 million who lack health insurance.

The difficulty with their confidence is that there's no way of knowing how these methods would work out on a national scale. What happens if the allowable national spending total is reached before year's end? How will the public react if competition to hold down costs leads to restraints in the uses of promising technologies? Who takes the rap for denying a liver transplant for a fetching child?

Bill Clinton has stressed that uncontrolled medical spending is sapping the economy and failing to cover the health needs of all the American people. The problem has been formulated in economic terms -- medical extravagance diverts resources from more profitable uses.

But America's health-care problem is mainly cultural: Along with competent care, we also expect miracles from the medical system. And even if the expectation is unrealistic, we don't want bookkeepers intruding on hopes and dreams.

Daniel S. Greenberg is a syndicated columnist specializing in the politics of science and health.

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