Reflection number one is that there is a greater demand for medical services in America than can possibly be paid for. The tab is already 16% of GDP – just under a sixth – or more than one day every week just for this. Half of the 16% – more than a day every two weeks – goes to pay for each person’s terminal illness, the last few months of life. Will people be prepared to spend more than one day per fortnight all their working lives to relieve and extend their final hours? Unlikely.
The next thing to consider is that universal medical insurance does not mean universal availability. All the medical attention everybody can desire can never be available. There will necessarily be some limitation (triage), and if it’s not money it will be waiting time, drug and equipment access, or some other form of rationing. For instance, about half the Americans who should use Lipitor and the other statins are in fact receiving them, while less than a quarter of Britons do and only a sixth of Italians. (A high proportion of the free pills are discarded incidentally.) The U.S. has twice as many MRI units per capita as Italy, four times as many as Germany and eight times as many as France. As to delay, about 40% of British cancer patients never get to see an oncologist, and 20% of treatable colon cancer patients there are incurable by the time treatment at last becomes available.
By universal agreement, the U.S. offers the best treatment overall. And, in medical innovation, it’s no contest: We were central to 80% of the last 30 years’ medical advances; eighteen of the last 25 Nobel Prize winners in medicine are here. Five-year cancer survival in the U.S. is 63% for men and 66% for women; in Britain, it’s 45% and 53% respectively. Forty percent of cancer patients there never can visit an oncologist, and less than half of patients receive specialized treatment within the government’s stated objective of 18 weeks, which would be a very long time here. And of course the improvement in dentistry is remarkable. I have heard English country people say of a marriageable girl, “And she has her teeth,” meaning an efficient set of false teeth. (English agents parachuted in to occupied France in World Ware II routinely had their teeth deliberately wrecked to make their identity less obvious in case of capture.)
The W.H.O. puts the U.S. well down the list in health care, but that is on political grounds, such as our tax system, social programs, health insurance, and the like. In other words, our choices.
We often talk about our neighbor to the north, Canada, as offering possible solutions. Seen from there, however, all is not well. Using the MRI criterion, the U.S. has five times as many per capita as Canada. Most Canadians think their system requires a fundamental overhaul.
Another notion is that intrinsically, health care as a percentage of a middle-class person’s income may be no more expensive as a function of curative power than it was 100 years ago, say. In those days there were no antibiotics and no CAT and MRI scans. If you got an infection you could be in real trouble. Maternal mortality was 100 times as frequent as today. As to most afflictions, a shot of whisky, a lot of water, an aspirin and bed rest was most of what the doctor could usefully propose. “Look wise, say nothing, and grunt, was the great English physician Sir William Osler’s recommended approach for doctors.
We seem to have gained about ten years of life since that period, using the modern methods and tools that have become available. Many killers of my childhood have become extinct or controlled: polio, smallpox, scarlet fever, T.B., gout, and crippling arthritis have become rare. So the additional couple of thousand dollars per year of added life for much more effective treatment (and more comfortable life, e.g., hip replacement) seems a good deal.
Then there is the dilemma of lifestyle-created illness: the patient who has smoked all his life and now demands free care for emphysema, lung cancer or another tobacco-related afflictions or the fat patient with obesity-caused problems.
It’s the very end that’s not so clear. Prolonging the terminal illness amounts to trying to reverse mortality: a losing proposition.
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I have come to a perhaps surprising conclusion about medical care, which is that an older person in a big city should consider using a primary doctor who is not in the Medicare system. The reason is that the fee a G.P. collects for Medicare doesn’t justify spending a lot of time with a patient. And yet the older you get, the greater the likelihood that something serious will come along that a short examination might miss, so that you only address the problem after it has gotten too late. A private doctor can take more time.
Another observation – quite obvious, this time – is that getting as little as half an hour of Pilates-type exercise twice a week is extremely valuable – perhaps indispensable after a certain age. My brother, who is pushing 90, fell and hurt himself a while back. Medicare paid for a young woman from the Visiting Nurse Service to come in and by way of rehabilitation lead him through exercises. He found her so valuable that he continued her on his own. In due course I did the same: a solid half-hour twice a week. A bit exhausting, but immensely beneficial. All sorts of muscles slowly get stronger and stronger, and balance improves. For the less-used muscles the difference between nothing and a little is very great indeed. ■