PHILADELPHIA REFLECTIONS
Musings of a Philadelphia Physician who has served the community for six decades

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The Shape of Lifetime Healthcare Costs

Lifetime health costs can be predicted, in the long run, to reduce themselves to costs in the first year of life, and in the last year of life. There were be some accidents, and some self-inflicted diseases. There may even be some new disease epidemics, and some wars. In the long run, however, science will eliminate more diseases, and engineering will make the cures cheaper. We aren't there, yet, but we are getting there, and it seems inescapable that health costs will go down. At first, they will go down as cost per year of life. Later, they will just go down, no matter how you figure it.

First, there is obstetrics. Everybody has to be born, so probably there have to be costs associated with birth. In recent decades, we have gone from eight-children families to, at most, two-children families. This has largely been accomplished by birth control, but a major factor has also been the delay of young women in having their first child. Unfortunately, having children at a later age is accompanied by increased incidence of difficult childbirth, increased incidence of birth defects, more disability and longer recuperation. Taken all together, these features of senescent obstetrics have led to the concept of the "valuable baby" to denote just about the last biological chance to have a child before the menopause sets in. Taken all together, these factors lead to a greatly increased incidence of Caesarian Section, and much more concern and cost associated with a normal phenomenon. Painful labor was once part of life; nowadays, anesthesia is available, so let's have it. Obstetrical costs have soared.

Unfortunately, since paying for medical care is riddled with cross-subsidies, it inevitably follows that since Obstetrics is absolutely essential, it is overcharged. Part of this is due to the fact that it is very hard work for the obstetrician. One friend of mine, on retiring from Obstetrics observed that he had practiced OB for eighty years. "Forty years during the day, and forty years at night." During World War II, my father-in-law was just about the only obstetrician in his city, and for four years delivered more than four hundred babies a year. The law of averages made a lot of these babies come at roughly the same time, in three hospitals; since he practiced in the snow belt of upstate New York, there were five months every winter when snow covered the ground, sometimes three feet deep. And now, the punch line. Almost every obstetrician in America has been sued by a patient at least once, and obstetrics carries the highest premiums for malpractice premiums of any specialty. Obstetrics is a difficult field: the high malpractice insurance costs push up fees, high fees breed resentment and more lawsuits. Someone who is closer to the field will have to relate whether this epidemic of obstetrical lawsuits is the fault of the lawyers or the patients, or the husbands or the grandmothers. Surely it cannot be the fault of the obstetricians, who by this time are ready to stand on their heads to prevent any more lawsuits. In a sense, it is probably the fault of the whole society. There is a great deal of guilt feeling about participating in the causes of this tragedy.

And finally, there is death. It has to be true that increasing life expectancy is partly attributable to recovering from other illnesses from which a person would formerly have died, and partly due to extending the period that it takes to die from what would otherwise have killed that person earlier. The first example would be the heart attack that didn't happen; the second would be dying of kidney failure with and without renal dialysis. Taking longer to die of a chronic illness usually contributes less to improved longevity than curing or preventing a disease entirely; treating chronic illness is therefore generally more expensive. Higher or lower average costs will therefore depend heavily on whether we have a higher proportion of chronic illness. Tuberculosis would be an example to the contrary. That particular chronic illness got largely eliminated, but most chronic illnesses just linger on. At present, eliminating chronic diseases looks as though it would save most money, although eliminating any disease will save some.

In between life and death, it make most economic advantage to put someone back to work, and therefore it is economically best to concentrate on the working years from 18-70, and maybe to extend them to 75. It must be noticed that getting young people to work earlier would be even more beneficial, and therefore extending the years of education or marginal unemployment is a step in the opposite direction. But that is not presently seen as a medical issue. But curing schizophrenia, which ordinarily appears earlier in life, would be of greater economic advantage than curing Alzheimer's Disease. By extension, reducing the proportion of mentally retarded children would be of still greater advantage. Indeed, my local school district spends 8% of its budget on mentally handicapped. The economic disaster of delayed childbirth is therefore more expensive to society than is generally recognized, so the benefits of doing something about it are less expensive than they seem. It follows that the same can be said of crippling accidents and self-inflicted recreational drugs. It might even be of value to construct a national budget of such recoverable costs, so that progress or lack of it, could be measured continuously.

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