The Washington Post Column

Health Care That Spares No Expense

Running down the stairs the other day, my 5-year-old son leaped, as he often does, onto the banister — and fell, as he previously never had, onto the floor eight feet below. When a child screams that he can’t walk, you take him to the emergency room, and so I did. But by the time we got there, he could walk “just a little bit” and I began to wonder if we ought to have waited. Nevertheless, upon hearing the story, the emergency staff went into high gear: X-rays, CAT scan, intravenous drip, blood tests, urine tests, EKG. At midnight they announced that they wanted to put him in an ambulance and send him for observation to another hospital. I said no. I signed a form, acknowledging that the risks of what I was doing included “death.” My son walked (making faces) out to the car, and we went home.

The following day, someone asked me how I’d had the nerve to just leave like that, and I found it hard to explain. There was nothing wrong with the emergency room doctors, who were both professional and kind. But they did seem to be operating by a preestablished playbook — one with little consideration for juvenile hypochondria on the one hand, and with an enormous predilection for overkill on the other. They had amazing, space-age, high-tech equipment, which, fortunately, no one else was using that night. They must have calculated, although they denied it when I asked, that mothers of 5-year-olds with undetected internal injuries are prone to lawsuits. They must have realized I had insurance. So — just to be certain — they carried out every conceivable test, even some that might have been unnecessary, or very expensive, or both.

All of this, I realize, is a long-winded way of getting to the subject of Medicare reform, Dick Gephardt’s health care plan and the Medicaid-induced state budget crises, but it is not as irrelevant as it might seem. A part of the current health care debate is about costs: General Electric reckons the price of health insurance for its employees has risen 45 percent since 1999. A part of the debate is about who should pay: General Electric’s employees have already been on strike, and may strike again, because the company wants them to absorb some of the rise. The rest of the debate is about the 40 million people who don’t have health insurance at all, because costs are so high that nobody can pay.

In response, Democratic presidential candidates and Republican congressional staffers are making claims about the greater fairness of government health insurance and the greater efficiency of private health insurance, respectively. Some tout the virtues of managed care, others believe the solution lies in tort reform. But the real problem is far deeper. We have come to expect, in this country, very high-tech health care, delivered without reference to price and thorough to the point of parody. Our doctors meet our expectations. No disease is too rare to test for, no technology is too expensive to use, and fear of litigation is not the only explanation. I suspect that nine out of 10 people would have reacted to my account of my son’s over-the-top emergency room experience as another friend did: “Weren’t you relieved?”

No doubt about it, this is the kind of health care we demand, and it makes us feel safer. But does it make us healthier? That’s less clear. Study after study shows that the number of operations conducted in a particular district doesn’t necessarily correlate with the health of that district. According to figures from the Organization for Economic Cooperation and Development, the United States spends almost twice as much per capita on health care as other developed countries, yet life expectancy here is actually lower than it is in about half of them. Despite the incredible medical advances of the past few decades, the less spectacular achievements of public health departments — clean water, unspoiled food, vaccinations — have probably had greater impact on our longevity and well-being.

None of which is to say we shouldn’t keep arguing about the best ways to finance health care or should play down the importance of tort reform. But it’s also clear that we need to keep better track of which procedures are really necessary, which aren’t and which give value for money. Health insurance needs to be redesigned not merely to create bureaucratic efficiencies but also to get both doctors and patients thinking and talking about costs. “Rationing” is a dirty word in this country, and many believe it’s immoral to talk about “price” and “health” in the same sentence. But if the high cost of my son’s emergency room visit means insurance premiums rise — and similar care then isn’t available to someone who really needs it — isn’t that immoral too?