David W Stewart - Healthy, Wealthy or Wise?: Issues in American Health Care Policy: Issues in American Health Care Policy

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HEALTHY, WEALTHY, OR WISE?

HEALTHY, WEALTHY, OR WISE?

Issues in American Health Care Policy

CHARLES T. STEWART, JR.

First published 1995 by M.E. Sharpe

Published 2015 by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
711 Third Avenue, New York, NY 10017, USA

Routledge is an imprint of the Taylor & Francis Group, an informa business

Copyright 1995 Taylor & Francis. All rights reserved.

No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers.

Notices
No responsibility is assumed by the publisher for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use of operation of any methods, products, instructions or ideas contained in the material herein.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe.

Library of Congress Cataloging-in-Publication Data

Stewart, Charles T., 1922-
Healthy, wealthy, or wise?: issues in American health care policy /
Charles T. Stewart, Jr.
p. cm.
Includes bibliographical references and index.
ISBN 1-56324-504-3 (hbk.).
ISBN 1-56324-505-1 (pbk.)
1. Medical policyUnited States. 2. Medical economicsUnited States.
3. Insurance, HealthUnited States. 4. Medical care, Cost ofUnited States.
I. Title.
RA395.A3S82 1995
362.1'0973dc20 956892
CIP

ISBN 13: 9781563245053 (pbk)
ISBN 13: 9781563245046 (hbk)

Contents

For many years I have been concerned about the overemphasis on medical treatment in the maintenance of good health.1 Medical care was, and remains, inefficient. But what precipitated work on this book was a foreboding that the sustained upward creep in the share of gross national product (GNP) going to the health care industry would erode the living standards of my childrens generation. I fear for their future, when in the second decade of the twenty-first century the postWorld War II baby-boom generation achieves retirement age. At that time, living standards could experience a sharp drop.

I am concerned about health costs, not over the next few years, but in the next thirty years. With continued growth in technology, in the population over sixty-five years of age, and in medical care costs, this industry, which absorbed 5.3 percent of GNP in 1960 and now takes 14 percent, is projected to absorb nearly one-third of GNP by the year 2030.2 We could be spending almost as much on other health care issues: environmental health and household and workplace safety. These large increases in share of GNP devoted to health care imply a decreasing share of private income available for other goods and services; they also mean that most government expenditures will be needed for health care, social security, and interest payments on the debt, with little left for anything else. Resources available for private investment and research other than medical research will be reduced, slowing economic growth. Living standards will have to fall if radical change is not implemented fairly soon.

This book examines the varied causes of the rapid increase in the cost of health care over the past three decades and considers the transformation of our health care delivery system that must occur early in the twenty-first century if private standards of living are not to decline and all other government social and economic programs are not to be starved. Proposals under discussion today would not reduce health care costs. They might slow down the future rate of increase, but that is not enough; that simply puts off for a few years the consequences outlined above. The share of GNP devoted to health care is excessive now, and it must be cut.

What follows is not a proposal about specific policies but an analysis of what must be done if health goals are to be attained without sacrificing everything else: why and what, not how. The obstacles in the way of a wise use of health care resources are not the difficulties in deciding what we want, although our wants often conflict with one another. Nor is our main problem ignorance of how to get from where we are to where we want to go. The principal obstacle is the opposition of powerful groups who stand to lose, or fear they may lose, from the radical reorganization of the health care industry needed to safeguard living standards and achieve a more productive use of valuable resources.

I have talked to many people about the issues raised in this book. Some of their ideas, information, and experiences are reflected in it. I should mention my wife, Nancy Thayer, my daughters, Eileen and Jocelyn, and my sister Anna Louisa McCartney, who made substantive contributions as well as providing moral support. Richard Scheffler will be surprised to know that conversations some years ago made a contribution. Mary Ann Baily and Thomas Moore are a continuing source of information and insight. They will not agree with everything I say, and I retain the same right toward them. To repeat a confession I heard many years ago from Walter Buckingham of Georgia Tech, I agree with myself at least 90 percent of the time. But all the facts are never in. On some minor issues my mind could be changed in the future. But not on the major findings and conclusions.

Notes

1. Charles T. Stewart, Jr., Allocation of Resources to Health, Journal of Human Resources 6 (Winter 1971): 10322.

2. Sally Burner, Daniel Waldo, and David McKusick, National Health Care Expenditure Projections through 2030, Health Care Financing Review 14, no. 1 (Fall 1992): 129.

1
Determinants of Health

Salud! Skoal! A votre sant! To your health! Drinking alcohol is no longer recommended, but the universality of the salutation bears witness to our ever-present concern about our health.1 There must be something we can do about our state of health, besides drinking toasts in its service; otherwise our concern would be misplaced. In fact, our health is the outcome of four basic determinants:

Our genetic endowment, over which we exercise no choice at all, although our parents may have had it in mind

The environment in which we live, over which individuals usually have no control, although they may choose to change environments, but over which individuals organized for collective action can exert substantial influence

Our lifestyle, over which we can exercise substantial choice, within the constraints of the second determinant

Health care, including the treatment of departures from good health and preventive measures other than changes in lifestyle and environment

The Determinants of Health

Genetic Endowment

Individuals cannot influence their genetic endowment. Nevertheless, it may change over time, through choice of mates or through differential mortality and fertility rates. Natural selection has played a major role in resistance to illness. The isolated populations of the Americas proved highly susceptible to measles, tuberculosis, and various infectious diseases that were relatively mild in populations exposed to them for many generations. The survivors were those with greater natural resistance, which they tended to transmit to their offspring. A similar effect was the outcome of the Black Death in Europe in the fourteenth century.

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