The Sickness in Medicine

...Why is that...

...And yet, with the aging of our population and the continuing climb in the cost of medicine, many other experts are not nearly so sanguine...

...Even if there isn't, lavishing money on corporate medicine has its downsides...

...In Boston, a woman suffering a heart attack is turned away from emergency rooms full of the uninsured...

...The IMF and World Bank require debt-ridden African countries to dismantle their public health facilities to make way for private fee-based clinics...

...They don't consider more better and new best...

...The basic story line, no-insurance=disaster-waiting-to-happen, is a staple of hospital dramas and Hollywood films, after all...

...Slack public health efforts, marginally beneficial and overpriced drugs, and unnecessary procedures performed not to protect patients but to protect physicians from litigation, are part of the answer...

...So, too, is Cohn...

...Sonia Shah is the author of "The Body Hunters: Testing New Drugs on the World's Poorest Patients" and "Crude: The Story of Oil...

...In countries where safe food and clean water are hardly assured, the health ramifications may be serious, indeed...

...They spend less than 8 percent of their GDP on health care, while Americans spend 16 percent...

...Jonathan Cohn's new book, Sick: The Untold Story of America's Health Care Crisis-and the People Who Pay the Price, details some of those tragedies...

...Between the 1970s and 1990s, the cost of gaining a year of life for a person over sixty-five has skyrocketed from $46,800 in medical services to nearly $150,000...

...Cohn elevates one: the crisis in paying for it all...

...The uninsured are less likely to have regular doctors," we are told...

...It's true that, in 1999, for example, the U.S...

...Bad food, dirty air, and dangerous working conditions-precursors to the heart disease, lung conditions, and diabetes prominently featured in Cohn's stories-play as much of a role in these tragedies as the lack of medical care...

...Likewise, he condemns an HMO that wouldn't authorize neurological tests for an injured boy "on the theory that the tests weren't medically necessary...

...In Denver, an insurer cuts short a mentally ill woman's third hospitalization...

...The dramatic power of Cohn's medical tragedies pivots on the national mythology that more medicine heals all...

...Donald Barr, recently noted in The New England Journal of Medicine...

...With our trillions of dollars, we could afford a much higher cap, or perhaps no cap at all, he implies with cornu-copian aplomb...

...But Cohn treats the for-profit biomedical industry with kid gloves...

...None of this, sadly, is particularly new or untold, despite Cohn's provocative subtitle...

...But streamlining bureaucracy is only one part of the equation in implementing universal coverage...

...This can get a bit tedious, which is not helped by Cohn's penchant for stating what has by now become obvious...

...More suggestively, he badmouths insurers that "offered financial bonuses to doctors for ordering fewer tests, performing fewer procedures, and prescribing fewer drugs...

...He applauds drugs such as hypertension drug Tracleer, which costs $3,000 for sixty pills, bemoaning insurers who fail to pay for them...

...Others are sued by Catholic hospitals who can no longer afford to ante up for charity care...

...She kills herself...

...Cohn seems appalled that health insurance companies are in the business to make money, but their profit margins are dwarfed by those of the major drug companies, selling $3,000 bottles of Tracleer...

...In the United Kingdom, for example, the government considers any treatment that costs more than $53,000 for a single quality-adjusted year of life too much and won't pay for it...

...They don't allow direct-to-consumer advertising, don't automatically pay for the latest thousand-dollar brand-name meds, and limit heroic surgeries...

...The national health plans that Cohn champions work because they provide cost-effective medicine...

...Better housing, clean water, and safe food "account for many times more years added to our life expectancy than do all aspects of medical care combined," as a Stanford physician, Dr...

...When the expensive therapies to support profoundly ill prematurely born twins are deemed medically unnecessary by an insurance company, he allows that "the company's statement was true . . . [but] the Hilsabecks didn't want to give up even a modest chance...

...That's because the Brits have national health care "on the cheap," Cohn says...

...By Sonia Shah Americans spend more money on health care than anyone else in the world, but we fail to insure more than forty-six million people among us, a national defect that daily delivers thousands of private miseries...

...spent nearly $300 billion on administering its fractious, piecemeal health insurance system, and that private insurers' administrative expenses are two and a half times greater than public programs...

...Nonetheless, Cohn milks his material for all the drama he can get, narrating each story in portentous detail: "The home had potential...

...In the United States, approved drugs kill more than 100,000 Americans every year, making adverse reactions to pill-popping the fifth-leading cause of death in the country...

...Within days, he's dead...

...In other words, our health care crisis is more than just a question of who picks up the bill...

...There's a sickness in medicine itself...

...He critiques government programs that require patients to substitute brand-name drugs for generic drugs, despite the fact that such drugs are orders of magnitude cheaper and pharmacologically identical...

...We never hear from insurers themselves in these pages, so we don't know how much of private insurers' cost-cutting is driven by profit concerns and how much by the cost of the medical goods themselves...

...Cohn himself rehashes stories from already published reports, including his own piece in The New York Times Magazine...

...That's a form of control to which Americans are notoriously resistant...

...Cohn's litany of medical tragedy concludes optimistically, however...

...We can do more and do better, all at once," he writes...

...She dies...

...But for all of that lavish spending, we got fewer physicians, nurses, hospital beds, MRIs, and CT scans per capita, higher infant mortality rates, shorter life expectancy, and a lower human development rating than industrialized countries that spend about half as much and that cover everyone...

...Is it...

...Its 2,400 square feet included three bedrooms, perfect for a young couple, plus a top floor whose windows revealed almost 360-degree views...

...Every other industrialized country with national health coverage also rigorously controls costs, independently evaluating new drugs and medical technologies and paying only for those that are clinically valuable and cost-effective...

...The man who stops taking his prescription drugs sickens, but "Pat couldn't be sure that Ernie was suffering because he wasn't taking his medications...

...Just as drug companies and medical device manufacturers insist that their products are expensive because they are so clinically valuable, so too does Cohn...

...You can't argue with that...

...She dies, leaving her widowed husband with a $40,000 bill to Sloan-Kettering...

...They're baffled by insurers' endless bureaucracy...

...We're also exporting industrial medicine overseas, demanding that impoverished Thais and Indians shell out top dollar for brand-name drugs...

...Cohn's subjects are hassled and cut off by insurance companies because they become too sick or too poor for insurers to profitably cover them...

...What if they weren't...

...Why is less necessarily bad...

...And yet, as Cohn admits, "Nobody can ever know for certain whether regular medical care could have pushed Betsy's care into remission or at least contained it long enough to give her a few extra years of life...

...Why let the developers of medical products off the hook so easily...

...But the devil, as always, is in the details...

...After all, the biggest health gains- the twenty-year jump in life expectancy that emerged between 1900 and 1950-occurred before the emergence of scientific medicine, with its high-tech diagnostics, vaccines, and drugs...

...He blames a heart attack death on the cessation of Plavix, a brand-name drug sold by Bristol-Myers Squibb...

...The United States spent nearly $6,700 per capita on health care last year-a staggering $2 trillion, or 16 percent of GDP-a greater sum in total and more proportionally than any other country in the world...

...Aha...

...In upstate New York, an uninsured woman fails to seek treatment for her cancer before it metastasizes...

...With some form of national health insurance, we'd rid ourselves of the insurance companies' costly bureaucracy, freeing up enough cash to cover everyone...

...It's surely wrong to deprive the poor and sick of services available to the wealthy, but it's also misleading to imply that more medicine would have saved these lives...

...Surely there is some threshold at which this trend becomes unsustainable...

...In ten case studies, Cohn, a senior editor at The New Republic, retells the woes of the uninsured and underinsured who fall ill, with predictably catastrophic results...

...In Tennessee, an uninsured man poisoned by years of exposure to industrial fumes stops taking the brand-name drug he can no longer afford...

...This he blames squarely on the privatization of employer-based health insurance, which makes its profitable living by shortchanging the poor and the ill...

...Bombarded with endless hype from the biomedical industry that more is better and new is best, we've become deeply attached to easy access to a plethora of high-tech, brand-name biomedical products-whether they are clinically valuable and cost-effective or not...

...It is possible to have hospitals full of high technology and emergency departments with room for all comers," he writes, "for people to choose their doctors and have a say in their treatments . . . to make the economy more free and more efficient . . . to do all this for everybody, not just an economically or medically privileged few, in a way we can all find affordable...

...And so it is disappointing that Cohn sidesteps the question of value and cost-effectiveness in the biomedical industry...

...Such stories could throw light on a number of facets of America's health care crisis, from the skyrocketing cost of medicine, to the pandemic of lifestyle and environmental diseases, such as diabetes and heart disease that require costly medicine, to the precipitous aging of the population...

...She can be reached at www.soniashah.com...

...Some spend hours in city hospitals waiting for crowded, noisy rooms with dirty bathrooms...

...And people die despite prompt medical care (and sometimes because of it) all the time...

...He says, simply, that government rationing, however it might pan out, would be more transparent, equitable, and less painful than our current piecemeal, private system that rations care by depriving it to the poorest and sickest...

...I suspect that what Cohn was really avoiding was a politically divisive discussion of rationing and what it might mean...

...As a result, they miss out on a lot of routine screenings that insured Americans get...