Maggie Eaton

The current American medical system is in trouble. The number of nonelderly Americans without medical coverage exceeded 47 million in 2012, and these people too often delay seeking medical care until their conditions become so dire that costly emergency and intensive care is required. Obesity rates are skyrocketing, leading to the increasing development of chronic medical conditions that require frequent and costly medical intervention.

These and other trends are placing inordinate demands on our medical system not staffed or funded sufficiently to remain viable. Partly because of increasing rates of retirement, the physician supply will increase by only 7 percent in the next 10 years. Over the same time, the Census Bureau projects a 36-percent growth in the number of Americans over age 65 who are often the greatest consumers of health care. These problems are serious, but funding health care seems to invoke the most concern of all.

Here are some sobering statistics. The Centers for Medicare and Medicaid Services has reported that the government, businesses and households will spend $2.9 trillion on health care this year – about 18 percent of the U.S. economy. One would think this vast amount of spending would result in a healthier, longer-living population. But that is not the case. Despite spending more on health care than any other country in the world, the U.S. ranks 27th in average-life expectancy and 44th in infant mortality. Because we don’t fund preventive health care, we spend inordinate amounts of money on patients with multiple chronic diseases and injuries, many of them self-induced because of poor lifestyle choices. And because we place such high value on medical technology, we fund aggressive end-of-life intensive care that has a very low probability of success. The technology and techniques used to achieve small increases in lifespan often lead to a miserable and undignified prequel to death.

These multiple imbalances, left in place, mean the U.S. health care system will become unsustainable in the next 25 years. Asking the U.S. mega health care system to become nimble enough to meet the rising demand without ruining the economy has been likened to asking an elephant to learn how to dance.

The health care system will be unsustainable in 25 years.

Obviously, drastic changes are needed. We need to aim for what we want – a healthier population and a cost-effective and efficient health care system. What we have now is a system geared to treating the sick and injured. What we need is a system that strives more to keep people healthy, which is better for people and cheaper than treating the sick.

An example of this kind of approach took place in Camden, N.J., where one physician discovered the existence of medical “hot spots” where people were the sickest. He found, for instance, that over a seven-year span, about 900 people in two buildings accounted for more than 4,000 hospital visits and about $200 million in health care bills. The physician’s solution was to place health care providers in these hot spots and not only provide health care to stabilize and control their illnesses, but use social service workers to address the causes of, and thus reduce the incidence of, their need for costly inpatient care.

This approach led to significant reductions in medical costs. Adopting this kind of thinking locally might prompt a coalition between hospitals and gang violence and drunk driving prevention task forces to reduce the incidence of injuries and thus the cost of trauma care. Coordinated community-based health care more easily prevents the tragic consequences of uncontrolled chronic diseases. Community access to birth control and prenatal care can lessen the health risks of pregnancy and the burden of intensive care for newborns. People who make end-of-life plans can avoid the kinds of traumatic and costly deaths that occur in an ICU instead of at hospice or at home. Expansion of childhood health education, funding research into preventable causes of cancers, allowing food stamps to be used at farmers markets, expanding the medical education system to produce more primary care providers are among the small and large changes that are prompted when the focus is on keeping patients healthy and out of the hospital.

Other countries experiment with even more radical approaches. Japan, for instance, officially recognized the relationship between obesity and disease and instituted a law in 2008 that requires companies and local governments to measure people between the ages of 40 and 74 as part of their annual checkups. People who exceed the healthy size limits set by an international health care organization are required to undergo weight loss programs. The employers whose employees fail to achieve healthy targets are required to pay more for health care. Unlike Japan, Americans are currently, as individuals, unwilling to pay for the consequences of their poor health habits. But unless we adopt comprehensive health care policies that address the underlying drivers of poor health, we will not be able to preserve the productivity and quality of life of our people or achieve cost reductions that are required for a viable health care system. These things are necessary to get the elephant high stepping.

MAGGIE EATON is currently Scholar Emerita at the Stanford University Center for Biomedical Ethics, a trustee of the Natividad Medical Center in and is a member of the steering committee of Sustainable Carmel.

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