Health care's ugliest truth

By D.J. Tice

The basic trouble with health care is simple - and disagreeable. Our reluctance to face it is preventing a frank debate about the costs pushing America toward economic crisis.

A debate of sorts is under way, largely between President Obama and Rep. Paul Ryan (R., Wis.). Focused on the ruinously mounting costs of federal health-care programs - Medicare and Medicaid - their faceoff is good as far as it goes. Unfortunately, it also goes in circles, thanks to an eagerness to ignore a reality that's absurdly obvious but apparently needs to be noted: Health care always fails in the end.

Naturally enough, what people want from health care is health - and life. Yet what each of us gets, sooner or later, is sickness and death. Given this grim reality, the cost of chasing the rainbow's end can only grow.

We don't have this problem with other things we desire. At least in an advanced economy like America's, we can produce enough food, housing, clothing, and cellphones (and then some). It's human nature to want more and better, but in most areas, basic needs can be met and people can be left to decide how much to spend on them.

We have inequality and poverty. Not everyone can afford the food or clothing or housing he needs. But with health care, in the end, no one can get his most basic need met. Bill Gates and Warren Buffett, with all their billions, will eventually be unable to buy another day of wellness or life.

Obvious, yes, but we are missing what it means. Even though we ultimately can't satisfy the demand for health, the health-care industry does supply an endless cornucopia of treatments, drugs, devices, and techniques. Many are wonderful, extending and improving lives. Others provide more marginal benefits. Some are breathtakingly expensive, others pretty cheap - and sometimes the cheap ones are more beneficial than the costliest.

But because the supply of health-care services just keeps expanding, without conquering sickness and death, spending never stops increasing. Unless, somehow, we decide when enough is enough.

This is the real, painful challenge of health-care reform. To limit costs ultimately has to mean limiting care. How to limit care most wisely and justly - through central regulation, market competition, or some blend of the two - is the debate we should be having. But we're stuck trying to convince one another that only the other side would ever think of asking anybody to give up any health care.

Last month, Obama said health-care reform will "drive greater efficiency" and "reduce unnecessary spending" largely because it will "change the way we pay for health care." And if costs continue to soar despite the miracle cure of "payment reform"? Then, Obama said, "this approach will ... make additional savings by further improving Medicare."

Further improving Medicare? That's our last resort if all else fails?

Ryan was equally in denial in a recent newspaper column. He wrote that his plan to essentially privatize federal health programs by turning them into voucher systems is about "using competition to weed out inefficient providers, improve the quality of health care for seniors and drive costs down." We won't feel a thing.

Yet Obama and Ryan aren't the only ones recoiling from facing facts. Commenting on the competing cost-cutting plans, the New York Times worried that "it is not clear that ... goal can be met without harming providers or beneficiaries." The Economist fretted that it could mean "reducing the quality of care or passing more costs along to patients."

It's enough (almost) to make you pity the politicians - this apparent need to pretend that efficiency or accountability or purchasing power or competition or some magic incantation can cut trillions of dollars from health-care spending (because that's what we have to do) without denying anybody care, costing anybody more, or even pinching providers (unless they're "inefficient").

The bomb-throwers warning of "death panels" were, after all, on to something. However crudely, they at least confronted the truth that limiting costs means asking people to make peace with unwelcome limits to what we can accomplish in health care. That their concerns were labeled not just exaggerated but utterly ridiculous showed that America is not yet ready for a serious health-care debate.

No doubt great efficiencies in health care could be found. Finding them will be the secret to enjoying all the health-improving wonders America can actually afford. But until this debate confronts the fact that what we can afford in health care has boundaries, it will hardly be worth having.