Emphasize health services, not technology

Former Colorado Gov. Richard Lamm has been one of the sharpest critics of the U.S. health-care system for more than 20 years, and in his new book, The Brave New World of Health Care, he lays out his critique in its most complete form yet. For all its technological marvels, he says, American health care is "unsustainable, unaffordable, and inequitable, and needs to be substantially amended and revised."

Lamm was interviewed by Vincent Carroll, editor of the editorial pages. The interview has been edited for length and clarity.

Carroll: You've been pounding away for years at the thesis that our health-care system is on a collision course with the financial solvency of the nation.

Lamm:: I start off with the fact that we can't look just at health care alone. A previous generation has decided that government has an interest in income security, long-term care and health care. So we have to look generally at this broader picture of how we retire the baby boomers.

Second, I describe a world that has invented more health care than we can afford to pay for.

Third, I describe a health-care system that is technologically marvelous, filled with caring people, but which is not the best system in the world. You have a technologically brilliant system filled with the best doctors and hospitals - but community-wise it is totally inadequate. As many as 18,000 people died last year because of lack of health insurance. So I think a lot of the ethical issues that we talk about - should we keep somebody alive on a life-support system in a permanent vegetative state - is just absurd when a system has this terrific mortality and morbidity rate on it's conscience.

Carroll:You say we do not have the best health-care system in the world. If you were to have a health crisis today - heart attack, accident, whatever - where would you rather be rushed to a hospital? In the United States? Britain? Canada? Germany?

Lamm:: Nowhere else in the world. But would I brag to you that Colorado has the best education system in the world if it were preventing 15 percent of kids from getting an education? I am not an expert in the technology of health care. I am an expert in what a system is, and a system is in my opinion three things. It is, first, the technology, the infrastructure of health care, and nobody beats us in that. We're worlds ahead of the rest of the world.

But the second aspect to me is access to health care, and the third is the quality of health care. And so I get very upset that the United States in so many major indicators - infant mortality, life expectancy - is so far behind. So if we have a system that we can be proud of for its technology, we should be embarrassed for it in other respects.

Carroll:: How would you address the problems you identify without undermining the system's great strengths, which include bringing to middle-class Americans incredible treatments, drugs and surgeries that in many cases weren't even available a decade or so ago? Think of how many people now get hip replacements, and how long they would have waited in most other countries for such an operation - assuming they could get one at all.

Lamm:: That's an important question, but if we're going to retire the baby boomers we have to look a bit less at technological medicine and more at some of the services that are needed. So much of our technological innovation comes in areas that are only marginal. We spend billions of dollars replacing MRI machines, or mammography, that are only a little bit better than last year's models. Our health-care system has gone running technologically amuck and yet is socially inadequate.

Carroll:: You argue that the bulk of advances in longevity and quality of life in the past 200 years have to do with rising prosperity, not with medical advances per se.

Lamm:: People's best doctors are themselves; they've got to understand that. One of the things that I'm really talking about is the new sense of self-responsibility in health care. Just a few factors are the most likely indicators of future health: smoking, diet, the use of alcohol, those kinds of things.

We pay 15.3 percent of our gross national product in health care, whereas the rest of the world averages 10 or 11 percent. We pay roughly 40 percent more.

You mention technology: We have three times more intensive-care units than any other developed country, and yet we have about half the nursing homes we need. We don't get very much from this immense investment in intensive care.

Carroll:: Let's focus on some of the things you believe inflate health-care costs. Your book mentions fee-for-service, competition among hospitals for technology, and the tort tax, among other things.

Lamm:: It is very clear that to some degree health care is supply-side driven - in other words, by the amount of hospitals that you have, the number of specialists, the number of mammography machines, and so on. I think we've got to have a closer analysis of exactly what the health-care system needs because at any given time in community hospitals maybe a third of the beds are empty.

We perhaps have right here in Denver significantly more cardiologists than we realistically need. Fee-for-service medicine is one of the things that has to be examined because the most expensive piece of technology in the health-care system is a doctor's pen. About 80 percent of health-care costs flow from what the doctor orders or the doctor's tests require.

The most commonly asked question posed to critics of the system is, What if it were your mother? Well my answer is I always want my mother to have everything, but you can't build a health-care system a mother at a time. You can't build a modern health-care system an individual at a time and that's going to offend a lot of people. We only pay 17 cents out of pocket on the average health-care dollar.

Lamm:: Exactly. There's a universal dilemma in health care and it's this: We can't afford not to have a health-care insurance system, but once you have that system and only 17 cents is paid out of pocket we will always overconsume. We can't have everything the medical scientists have invented. That's the bad news; the good news is we can still have almost everything.

Carroll:: Your bottom line is that we have got to reconcile ourselves to some sort of rationing of medical care. If that's the case, I personally would like to see as much rationing as possible done by individuals by way of restructuring the system's incentives - through the tax code for example - so people become more discriminating consumers of health care. That would prevent a lot of the waste you worry about. The New York Times published a long article recently on how many billions of dollars are squandered just because so many people see doctors about back pain. A majority of backs tend to get better on their own or with common-sense care, yet so many people see doctors about their backs because they only pay a tiny fraction of the cost. But you're not sympathetic to self-rationing of the sort I'm suggesting, are you? You're more sympathetic to government rationing of the sort done in Canada, Britain and other countries. Am I being fair?

Lamm:: You're fair. I have no ideological problem with the market. But in health care, 30 percent of health care is spent on the sickest 1 percent of the people, 55 percent of health care is spent on the sickest 5 percent of the people, 70 percent of health care is spent on the sickest 10 percent of the people. Now those are largely frail elderly or desperately ill people. It's called concentration of expenditures. How do you educate people to be good consumers when they're in extremis?

Lamm:: I think that the German health-care system comes as close to a model if I'm forced to pick one. But one of the biggest issues that I'm trying to raise is the cultural expectations of America. Every American feels that they're entitled to the best health care and cost is no consideration.

Carroll:: You make some pretty specific recommendations regarding Medicare which include partial means testing, indexing the Part B premium to inflation, raising the deductible, and so on.

Lamm:: Both you and I know our current systems of handling retirement are unsustainable. Social Security is unsustainable. Medicare is unsustainable. I can see a path to Social Security's solvency where we raise the retirement age and do some other things. But with Medicare I can see no path.

I'm looking you in the eye and telling you I don't think you deserve a heart transplant if you're over 75. You just don't. We had 70,000 women give birth last year without adequate prenatal care. I was in Japan looking at the health-care system and I saw a wristwatch that if I were wearing right now and had a heart attack would automatically dial 911 and home the ambulance in on your office. Now would I feel entitled to it? Hey, I'm on Medicare. I paid my dues. We live in the world of the bionic man and the bionic woman. Somebody has to say we can't give the Hippocratic oath a blank check.

Carroll:: But you write that you would let people spend their own money if they wanted at age 77 to have a heart transplant.

Carroll:: Because those countries that have created a totally egalitarian, one-tier system of health care, such as Canada and Sweden, have failed to quash individual choice. In Canada the well-off go to the United States and elsewhere for treatment. In Sweden they go to London.

Lamm:: I don't tell people how to spend their money. The government shouldn't tell people how big of a house that they can buy, or how fancy a car they can own. So once you get beyond that point then I argue that we all have to belong to health plans, and those health plans have to say how many headaches you get before you get a CAT scan. It will say how many times you will get your PSA test, or a colonoscopy performed and if you want it performed more often than that you're going to have to be on your own.

Carroll:: Another example you've used is if you want a mammogram under the age of 40.

Lamm:: Great example. My wife had breast cancer and I'm very worried about my daughter, but you have to set rules. Maybe if you have a family indicator in breast cancer or certainly if you have a lump you should have a mammogram. But you don't give every young woman a mammogram.

Carroll:: You've been at this issue a long time. Do you see any progress in terms of American attitudes moving in the direction you would like to see?

Lamm:: We're still not engaged in the issue. But history is on my side. When the baby boomers retire, we're going to be hit with this between the eyes. We're going to have to make a series of decisions and ask ourselves how do we develop a compassionate society that isn't driven by the cultural expectations of self-indulged America. We're going to have to set some limits.

"For all its technological marvels, he says, American health care is "unsustainable, unaffordable, and inequitable, and needs to be substantially amended and revised."

BS. The *only* reason we have *any* "problems" now is because there is just enough *socialist/Nazi* flim-flam going on in medical services now. We do not have a perfect capitalist system in place in medicine. Yet capitalism continues to be blamed for the problems - rather than all the garbage commie ideas that have spread in it for decades now.

Here's an example. HMOs were beloved of Democrats 10 years ago. Because they were all concerned about price (NOT cost), and they were a little microcosm of their socialist-paradise ideals. "Pay nothing", Wait for months for an appt, and get any old doctor they want to put up for you.

Now, the Democrats are treating HMOs like any other "corporation" - oh, those horrible, corrupt, greedy HMOs!!! The reason they don't work is because of their commie roots. But suddenly Demos try to equate them to any old "Big Business" they *naturally* hate.

No mention, BTW, of "we were wrong". You'd think they never wanted HMOs in the 1st place.

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