An excerpt from Balancing The Budget is a Progressive Priority.

It is our cultural fear of death and inability to discuss the limits of medicine to forestall death that enables the politics of health reform to be so potent.

When I did a post-doctoral fellowship in England in the mid-1990s, a professor I met who had lived in the U.S. explained to me why he thought health policy discussions in that nation were so much more honest and straightforward than were those in the U.S.  The U.K, he explained, was a country that believed reflexively in Original Sin, regardless of what an individual’s religious beliefs might be. They were not surprised when things were bad, and they fully expected them to get worse!  This general perspective held true he said for the weather, how England would do in the World Cup, as well as in health policy.  So, the English people weren’t surprised by waits for some medical procedures, for example, and preferred an honest discussion on how to make them as short as possible, to pretending that limits to what the NHS could afford to spend on health care did not exist.

In the U.S., he surmised, we believe in the perfectibility of humankind, again reflexively and without respect to religious views.  This means that we assume that with enough effort, energy and focus we can fix anything.  This of course runs counter to what I have termed the first law of health care systems: that everyone dies.

That everyone dies doesn’t mean that we shouldn’t attempt to prevent and treat illness, but that inevitably, we reach diminishing returns on the health care investments we make to forestall death.  It can be quite difficult to determine when this occurs, and harder still to decide what to do about it.  However, in the United States, we do not seem to even be able to ask the question that flows naturally from diminishing returns: is this procedure worth it?

Of course the answer is laden with many value judgments.  But not asking the question too has values, and means that we often spend substantial sums of money on care that may actually shorten lifespan and reduce quality of life, in the miniscule chance of achieving a miracle.  Our expectation that we should be able to conquer any disease if we just work hard enough hinders our ability to have honest, open and realistic conversations about the existence of limits in what medicine can do.  It is our culture’s inability to honestly wrestle with these limits, and practically coming to grips with the reality that everyone eventually dies, that is the root cause of why our health system is unsustainable.

Beginning to face this reality and ask the question “is it worth it?” is the only way we can address health care costs and transition to a sustainable system.

Can anyone say no?

As I was working on this book over the Christmas holidays of 2010, Blue Cross Blue Shield of North Carolina (BCBS NC) announced a new set of rules that govern when they (largest insurer in North Carolina with around 70 percent of the market share) will pay for spinal fusion surgery.  This is a surgical procedure that is designed to lessen lower back pain, which is a common chronic health condition that results in a great deal of suffering.  There has long been uncertainty about the best way to treat low back pain.

BCBS NC did not say they will never pay for spinal fusion surgery, but instead that they are tightening the criteria for when they will do so to ensure that that the procedure is warranted.  In other words, under some circumstances they will say no, we will not pay for spinal fusion surgery.  If we ever slow the rate of cost inflation in health care, there will be numerous instances like this—where we begin to spend less than we otherwise would have with no change.  Someone will have to say no to something that is likely to be provided by default if we are going to slow the rate of health care spending increase.  The possibilities of who could say no are patients and families, insurers, be they government or private, and health care providers.  If there are not any changes in how these actors currently think about and act in making health care decisions, we will not address health care costs.

So, we are left with the public saying they want to put an end to ”out of control health care spending” but most of these same individuals will decry the move by BCBS NC as rationing that is inappropriate.  Any comment from the public will be disproportionately weighted toward outrage that an insurance company may not cover the procedure in certain circumstances.  Persons without low back pain will not pay much attention, but those with the problem and advocates will decry the removal of a treatment option from some patients.  And many will assume that BCBS NC and any other private insurance company is only out to reduce their payout for care as a way to improve their bottom line.  They of course do have this as a motivation.  And the most likely outcome is that a procedure that is not proven to be better than other therapies yet costs many times more will be provided and paid for by BCBS NC.   Even if definitive research proof is found that the surgery is not worthwhile, such a technical answer is unlikely to prove persuasive without a change in how our culture talks about these sorts of issues.

Donald H. Taylor Jr. is an associate professor of public policy at Duke University and blogs at The Incidental Economist.  He is the author of Balancing The Budget is a Progressive Priority.

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