I waded into Jonathan Cohn’s “Creative Destruction: The Best Case Against Universal Health Care” with misgivings. But to my delight Cohn presents the “best case” and then demolishes it.
The “best case” is the argument that a free market health care system encourages innovation that leads to new treatments and cures. Yes, we devote 16 percent of our gross domestic product to health care, but our health care spending is driving innovation for the entire world. If the profit motive were removed from health care, say the “free market” advocates, innovative medical research would be squelched. And that’s a compelling argument.
However, there’s theory, and then there’s the real world. As Cohn says,
But it’s one thing to say that universal coverage could lead to less innovation or reduce the availability of high-tech care. It is quite another to say that it will do those things, which is the claim that opponents frequently make. That argument requires several leaps of logic, many of them highly suspect. The forces that produce innovation in medicine turn out to be a great deal more complicated than critics of universal coverage seem to grasp.
It turns out that in the real world the real innovations, the breakthroughs that take medical research into whole new directions, are generally not made by the private sector health care industry.
The great breakthroughs in the history of medicine, from the development of the polio vaccine to the identification of cancer-killing agents, did not take place because a for-profit company saw an opportunity and invested heavily in research. They happened because of scientists toiling in academic settings. “The nice thing about people like me in universities is that the great majority are not motivated by profit,” says Cynthia Kenyon, a renowned cancer researcher at the University of California at San Francisco. “If we were, we wouldn’t be here.” And, while the United States may be the world leader in this sort of research, that’s probably not–as critics of universal coverage frequently claim–because of our private insurance system. If anything, it’s because of the federal government.
The single biggest source of medical research funding, not just in the United States but in the entire world, is the National Institutes of Health (NIH): Last year, it spent more than $28 billion on research, accounting for about one-third of the total dollars spent on medical research and development in this country (and half the money spent at universities). The majority of that money pays for the kind of basic research that might someday unlock cures for killer diseases like Alzheimer’s, aids, and cancer. No other country has an institution that matches the NIH in scale. And that is probably the primary explanation for why so many of the intellectual breakthroughs in medical science happen here.
There is absolutely no reason why moving to a universal health care system would require cutting back on NIH research. In fact, since 2003 President Bush and his congressional allies have allowed NIH funding to stagnate. They needed room in the budget for other priorities, like tax cuts. “In this sense, the greatest threat to future medical breakthroughs may not be universal health care but the people who are trying so hard to fight it,” Cohn writes.
In fact, in the real world there are indications that the profit motive might be stifling innovation. Most of the private health care industry is focused on developing and marketing as many new, patented products as they can. As a result, much product and development research is focused on incremental improvements on those products that have made money in the past. Research that does not hold a promise of new product development, even if it might lead to cures, is shoved aside. For example, in this article in Genetic Engineering and Biotechnology News, the authors argue that cancer research needs to get away from tweaking products and move into areas that have clinical impact. Cohn writes,
As books like Marcia Angell’s The Truth About the Drug Companies and Merrill Goozner’s The $800 Million Pill point out, a lot of the alleged innovation we get from private industry just isn’t all that innovative. Rather than concentrating on developing true blockbusters, for the last decade or so the pharmaceutical industry has poured the lion’s share of its efforts into a parade of “me-too” drugs–close replicas of existing treatments that offer little in the way of new therapeutic advantages but generate enormous profits because they are patented and because companies have become exceedingly good at promoting their sales directly to consumers.
In some cases private industry has gone from creating products to cure diseases to tweaking diseases to sell more products. For example, the criteria for clinical depression have been so watered down that just about anyone having a bad hair day might fit the diagnosis. It seems obvious that Big Pharma is behind this — the better to sell large quantities of Zoloft and Paxil, my dears. This phenomenon, in turn, leads to misuse of drugs, more unfortunate side effects, clinical trials that show drugs have little effect on “depression” (because the trial subjects were not actually depressed), and the persistent notion that clinical depression isn’t a real disease and people who think they have it are just whiners. Those of us who really are clinically depressed may appreciate our Big Pharma meds, but we have major issues with the Big Pharma marketing departments.
Cohn writes of CT scanners, which are wonderful devices. However,
It’s the potential to sell many more such devices, at a very high cost, that has enticed companies like GE to invest so much money in them. In fact, compared to the rest of the developed world, the United States has a relatively high number of CT machines (although Japan has more). But experts have been warning for years of CT overuse, with physicians ordering up scans when old-fashioned examinations would do just fine. (Some experts even worry that over-reliance on scans may be leading to atrophied general exam skills among physicians.) Studies have shown that the mere presence of more CT scanners in a community tends to encourage more use of them–in part because the machine owners need to justify the cost of having invested in them. The more CT devices we buy, the less money we have for other kinds of medical care–including ones that would offer a lot more bang for the buck
And on and on. It’s an excellent article that I urge you to read and bookmark.
So far I’ve seen one reaction from a “free market” blogger, who simply ignores all of Cohn’s well-documented arguments and repeats the mantra:
The advantage of markets is that they foster innovation. They reward successful innovation. Moreover, they eliminate obsolete institutions and organizations.
Government is much more likely to protect incumbents. Regardless of whether it stifles innovative treatments, government will certainly stifle innovative ways to organize and deliver health care. Indeed, it already does so, with its restrictions on medical licensing and practice. A complete government takeover could only make things worse.
Wingnuts simply cannot process empirical evidence that their glorious theories don’t apply to the real world.
In other health care news, today Eugene Robinson discusses “socialized medicine” snake oil and a major study conducted this year by the Commonwealth Fund:
Respondents in the United States were less likely than those in the other countries to say their health-care system “works well” — and much more likely to see a need for “fundamental” change or a total overhaul. With 47 million Americans lacking health insurance, I suppose that shouldn’t be much of a surprise.
What did surprise me was the wealth of data refuting the general criticism that single-payer health-care systems are cold, impersonal and, well, uncaring. According to the survey, 80 percent of Americans have a regular doctor whom they usually see. That sounds pretty good, until you learn that 84 percent of Canadians, 88 percent of Australians, 89 percent of New Zealanders and Britons, 92 percent of Germans, and 100 percent of Dutch respondents surveyed said they had regular doctors. Marcus Welby, M.D., seems to have emigrated.
Okay, but what about the long waits for treatment under single-payer systems? The survey found that 49 percent of Americans said they could get a same-day or next-day doctor’s appointment when they were sick — as opposed to 75 percent of respondents in New Zealand, 65 percent in Germany, 58 percent in Britain and so on. Only in Canada was it more difficult to see a doctor within 48 hours.
It’s true that in the United States, the wait for elective surgery is likely to be shorter than in the other countries (except Germany, which has the shortest wait of all). But onerous delays of six months or more were significantly more common only in Australia, Canada and Britain.
And then there’s this:
The United States spends $6,697 per capita annually on health care, according to the survey — more than twice as much as any of the other countries surveyed. Americans were much more likely than any other national group to have spent at least $1,000 out of pocket on medical expenses over the past year. And, of course, 16 percent of Americans reported being uninsured, as opposed to essentially none in the other countries.
It makes sense, then, that far more Americans than respondents in the other countries reported that in the past year, they had failed to fill a prescription or skipped doses, experienced a medical problem but decided not to go to the doctor, or skipped a prescribed test, treatment or follow-up.
We may have a mess of a health care system, but I bet we beat the world at cooking up half-baked theories and clinging to them through thick and thin. Alas, disease and death are not theories.
Update: Andy Sullivan misses the point.