Deciding how to fund health care

The state of Maine, like every other governmental organization, is struggling to find an equitable way to fund the requirements of health care for its citizens. I fear this attempt is doomed to fail, primarily because the fundamental cause for the crisis has not been defined. All attempts to control the financing of health care throughout the world are in serious financial trouble. These include a purely governmentally funded system, such as exists in Great Britain and other European states, a single-payer system, as in Canada, and a combined governmental and private insurance, as exists in this country.

The reason for this problem is in some ways quite simple, but most groups studying the problem have ignored it. When I first became involved in medicine just after World War II, the health care costs were very reasonable; primarily because, compared to today, there was very little we had to offer in the areas of prevention, diagnosis and therapy.

Also, we had effective therapies for very few chronic or degenerative diseases, thus the cost of taking care of this group of diseases was not great. Since then there has been an explosion in our knowledge of all aspects of disease, including prevention, diagnosis and therapy. With this has been a massive increase in the number of tools available to medical science, and these tools have, for the most part, been extremely complex and consequently quite expensive both to obtain and maintain.

Several examples: In 1940, 100 percent of children with acute leukemia died, and as there was nothing to offer these children, the cost of caring for them was negligible. Now more than 70 percent of these children are cured, but the cure is complex, requiring procedures that by their very nature are expensive. Unlike the situation in 1945, we are now able to cure most cancers that arise in the young. After the World War II the field of medical oncology did not exist, primarily because there was practically nothing other than surgery that could be offered to these patients, thus the cost of taking care of a patient with cancer that could not be cured by surgery was negligible. Medical oncology is now one of the largest subspecialties in internal medicine, and nonsurgical therapeutic options to effect the course of essentially every cancer are available.

Many of these are very complex, and by their nature, very expensive. Heart disease is still the leading cause of death, but the mortality rate from heart disease has shown a remarkable drop. In 1945, we had no effective diagnostic tools or therapy for either coronary vascular disease or essential hypertension. Today we can do thallium stress tests, coronary angiograms, and if necessary, balloon dilation of blocked arteries or surgically bypass blocked coronary arteries. Our ability to control abnormal lipid levels and lower abnormally high blood pressure did not exist in 1945, now it is routine. The pharmaceutical industry has rightly been severely criticized for many excesses, but I know of no industry that contributed as much to the welfare of mankind or that devotes as high a percentage of earnings for research as does this industry. Our dollar today buys much more in effective health care than it did in 1945 but much more is available in health care that demands our dollar.

The level of progress described is true of essentially every disease and of every field of medicine, from neonatology to geriatric medicine. This illustrates what I believe is the fundamental cause of the financial crisis, that is, that the rapid advance of our ability to understand and control disease has been accompanied by a parallel, and probably justified, increase in the cost of providing that control.

It is my opinion that even if it were possible to do the impossible and create a system that was 100 percent efficient as to cost, with all the participants in the system receiving average lifetime earnings, society could not, as of today, afford to fund perfect medical care for all. The massive increase in knowledge and in the techniques available to medical science is just beginning, and most of us believe that in the near future the problems noted above will rapidly worsen. Until this is realized, accepted, and addressed by society as a whole, all attempts to derive an equitable system to fund health care are doomed to fail.

In some ways society, in its attempts to control costs, has compounded the problem. Graft, inefficiencies, and fraud certainly exist in health care, as they do in all human endeavors. It was initially believed that controlling these would reduce costs. To do so, multiple regulations have been put in place that have been a significant factor in increasing the cost of delivering health care. They do so by creating a huge bureaucracy that requires major financial support and also by substantially decreasing the efficiency of all individuals directly involved in health care. When I first started to practice medicine approximately 90 percent of my time was spent in delivering health care and 10 percent in administrative matters. Today I am able to spend 60 percent in delivering health care, and administrative tasks consume 40 percent of my time.

Consequently, it now takes nine physicians to do what six physicians did in the past. In 1958 my primary 700-bed hospital required three administrators to run the hospital and 4 clerks to run the record room. Now the same hospital has 400 beds, more than 80 administrators and requires more than 40 clerks in the record room whose primary function is to prepare charts for billing. Society must absorb these costs. Some controls are necessary to minimize the inequities that exist in health care, but it should be possible to do so in a way that the costs of these controls are not greater than the savings that result. It is obvious to anyone involved in the health care industry that as of today, the indirect and direct costs of these controls far outweigh the savings that result.

Society reluctantly soon will be forced to decide what fraction of the gross domestic product it is willing to allocate to the health industry, what segments of the health care industry it is willing to support and which segments should not be supported, and how to do all of this in the most efficient way, decisions that will be very difficult and divisive, but necessary.

Arthur J. Weiss, M.D. is director of the Oncology and Hematology Section at the Veterans Administration Hospital in Togus. The views expressed above are purely that of the author and in no way reflect the views of the VA Hospital or of any agency of the U.S. government.