Americans are both the fattest people in the world and the biggest spenders on health care. Both those facts can be traced, at least in part, to a common attitude.
First a few numbers. The latest global handbook from the Organisation for Economic Co-operation and Development (OECD) shows that 34 percent of Americans are obese by the criteria of the World Health Organisation. In health care spending, the United States leads with 17 percent of GDP. In both categories, U.S. numbers are almost twice as high as the average numbers of OECD members.
The extra fat accounts for only a small portion of the extra American spending on health care. Researchers recently estimated that the medical expenses caused by obesity, which is connected to problems such as high blood pressure, heart disease and diabetes, amounted to $147 billion in 2008. That number suggests that even if Americans were no fatter than the OECD average, they would only spend 3 percent less on health care than they do now.
I believe there is a more significant connection between the obesity problem and the amount Americans spend on health care than these numbers suggest. Both the choice to eat too much and the choice to pay up for almost everything labelled “medical expense” are spawned by an attitude which can be called health wilfulness. The United States leads the world in this attitude, but it, along with obesity and health care spending, is probably on the rise almost everywhere. It helps explain why spending on health care increased from 4 to 10 percent of GDP since 1960 for the entire OECD.
Health wilfulness is the belief that it is my right to decide what to do with my body. If I want to eat without concern for my health, so be it. When it comes to health care, I expect the modern medical system to satisfy my desires, whether for help in getting slim again or for heroic efforts to prolong my life. Money should not matter.
The attitude fits with the modern culture’s enthusiasm for individualism and consumer choice, but it has some unattractive consequences. The damage caused by a wilful approach to eating is plain to see. The damage caused by wilful health care is harder to see because it can be obscured by the sensitivity of life and death matters. Is it not better to favour life, whatever the cost? But the wilful approach to medical care has made the American system sickly. Too much is spent on care that pleases vain or desperate patients and family members, without doing much for health. As much as one-third of total spending is dedicated to care during the last year of life.
There would be less to complain about if the high cost of these wilful choices were born only by those who make them. But, direct payments from patients account for only 12 percent of the total medical spending in the United States. The rest of the funding comes from society as whole, through plans run either by governments or by heavily regulated insurers. In effect, health wilfulness is usually an individual’s decision about how to spend everyone’s money.
The socialisation of medical costs has much going for it. Both the mixed American and European systems and the more monolithic British arrangement provide the poor with care they could not otherwise afford. Socialisation also spreads the burden of expensive treatments over a lifetime and the costs of sickness over well and sick alike. But the combination of medical socialisation with health care individualism has increased total health spending and created involuntary subsidies from those who chose fewer interventions to those who choose more. In most rich countries, both the economy and justice would now be served by a partial de-socialisation of health care.
How to do it? One approach is already standard practice in many American and European arrangements – make patients pay part of the cost. These plans would be more effective and just if the fees were calibrated to incomes, so rich and poor people felt the same economic pain. (Speeding fines are set this way in Finland.) Another approach is to allow people to opt out of the socialisation of costs for selected treatments. They could choose an insurance plan which excludes, for example, serious operations for people over 80 or treatments for cancer which add less than one year to life expectancy. The frugal would pay less and get less. Alternatively, the standard health insurance policy could cover less than it currently does. Higher priced policies would be available so the most wilful could still satisfy their health care desires.
The practical details of medical de-socialisation – setting prices and dealing with late changes of mind – are tricky. But it’s worth a try. We’re more careful about expensive things when we have to pay for them out of our own pocket.