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How America’s Health Care Fell Ill
As modern medicine has grown ever more powerful, our ways of providing it and paying for it have gotten ever more wasteful, unaffordable, and unfair. An explanation and a possible first step toward a solution.
May/June 1992 | Volume 43, Issue 3
Perhaps the most astonishing thing about modern medicine is just how very, very modern it is. Ninety percent of the medicine being practiced today did not exist in 1950. Just two centuries ago medicine was an art, not a science at all, and people—whistling past the graveyard—joked that the difference between English doctors and French ones was that French doctors killed you while English ones let you die. Even sixty years ago there was usually little the medical profession could do once disease set in except alleviate some of the symptoms and let nature take its course.
When the distinguished physician and author Lewis Thomas was a young boy, in the 1920s, he often accompanied his physician father on house calls, and his father would talk with him about the patients he was seeing and the medicine he was practicing.
The new power to extend life, interacting with the deep impulse to stay alive, has had consequences we are only beginning to comprehend.
“I’m quite sure,” Thomas wrote years later, that “my father always hoped I would want to become a doctor, and that must have been part of the reason for taking me along on his visits. But the general drift of his conversation was intended to make clear to me, early on, the aspect of medicine that troubled him most all through his professional life; there were so many people needing help, and so little that he could do for any of them. It was necessary for him to be available, and to make all these calls at their homes, but I was not to have the idea that he could do anything much to change the course of their illnesses. It was important to my father that I understand this; it was a central feature of the profession.”
But as Lewis Thomas prepared to enter medical school himself, this age-old central feature began to fade away. Around 1930 the power of the doctor to cure and ameliorate disease started to increase substantially, and that power has continued to grow exponentially ever since.
One popular almanac gives a list of milestones in the history of medicine. The list is eighty items long, stretching back all the way to 2700 B.C., but of those eighty milestones, twenty-nine were achieved in the last sixty years. In other words, more than 36 percent of medicine’s most noteworthy triumphs have occurred in just the last 1.3 percent of medicine’s history. This new power to extend life, interacting with the deepest instinctual impulse of all living things—to stay alive—has had consequences that human society is only beginning to comprehend and to deal with.
Some of these consequences, of course, are trivial. Perhaps the most trivial is the disappearance of the house call itself. Dr. Thomas, Sr., could carry virtually the full armamentarium of the medicine of his day in a single black bag, and very nearly all of medical knowledge in his head. Today the general practitioner is a vanishing breed, and specialists cannot use their time effectively traveling from patient to patient. Other consequences, however, present some of the most profound moral dilemmas of our time. Since ancient Greece, doctors have fought death with all the power and passion at their disposal and for as long as life remained. Today, while the passion to heal remains as great as ever, the power has now become so mighty that we increasingly have the technical means to extend indefinitely the shadow, while often not the substance, of life. When doctors should cease their efforts and allow—perhaps, in some cases, even help—death to have its always inevitable victory is an issue that will not soon be settled, but it cannot be much longer evaded.
Somewhere in between lies the problem of how to pay for modern medicine, whose costs are rising faster than any other major national expenditure. In 1930 Americans spent $2.8 billion on health care—3.5 percent of the gross national product. That amounted to only $23 per person. The average physician that year earned less than $10,000.
In 1990 the country spent 235 times as much on medical care, $666.2 billion. That amounted to $2,566 per person and 12.2 percent of the gross national product. The average physician that year earned $132,550.
Netting inflation out of those figures, the country’s per capita medical costs have risen ten times in sixty years while the average physician’s earnings have risen less than three times. There is no end in sight. According to the Health Care Financing Administration, health expenditures will almost triple in the next ten years if current trends continue.
There are many reasons for this huge and accelerating increase in medical costs. Consider just the last decade. In the 1980s medical expenses in the United States increased 117 percent. Forty-three percent of the rise can be accounted for by the general inflation the country underwent, mostly in the early years of the decade. Ten percent can be attributed to population changes, for the American population is growing both larger and older. Fully 23 percent of the increased cost went to pay for technology, treatments, and pharmaceuticals that were simply not available in 1980, a measure of how very fast the science of medicine is advancing. But that leaves 24 percent of the increase unaccounted for. Unfortunately that remaining 24 percent is due solely to an inflation peculiar to the American medical system itself.