I kind of owe an article on how I would cut government health care expenditures in half by improving the efficiency of care. Unfortunately if I write everything I want to write, that article is going to be a long time in coming. So here's a "short" article on why I think a large fraction of all medical expenditures in the U.S. - like about half - are probably waste and could be cut out completely without affecting the quality of care, even with no other improvements in efficiency.
The first thing to understand is that the large majority of medical expenditures are not on things that happen to the young - where "young" means roughly "under 50". In fact, 75% of U.S. medical expenditures are on chronic diseases, which primarily affect old people - like my mother, who at 77 is on 7 different kinds of medication for things like diabetes, high blood pressure, and the side effects of others of the medications. And she's relatively healthy for her age! So if you're 30 or 40 years old, the vast majority of health care expenditures are on things that you've likely never even had to think about.
The second thing to understand is that the medical establishment has little knowledge of what causes these diseases. Rather, they treat symptoms. As one doctor puts it:
What would be the typical treatment of cardiovascular disease? First they check the cholesterol. High cholesterol over 200, they put you on cholesterol lowering drugs and what does it do? It shuts off your CoQ10. What does CoQ10 do? It is involved in the energy production and protection of little energy furnaces in every cell, so energy production goes way down.... One of the best treatments for a weak heart is CoQ10 for congestive heart failure. But medicine has no trouble shutting CoQ10 production off so that they can treat a number (cholesterol figure)....
As Gary Taubes puts it, doctors want to do something for their patients now, not do years of research to figure out what the right thing to do is. Regarding metabolic syndrome, which accounts for most of that chronic disease expenditure, he points out:
The urge to simplify a complex scientific situation so that physicians can apply it and their patients and the public embrace it has taken precedence over the scientific obligation of presenting the evidence with relentless honesty. The result is an enormous enterprise dedicated in theory to determining the relationship between diet, obesity, and disease, while dedicated in practice to convincing everyone involved, and the lay public, most of all, that the answers are already known and always have been - an enterprise, in other words, that purports to be a science and yet functions like a religion.
So basically most of that 75% of U.S. medical expenditure on chronic diseases doesn't work and likely makes things worse. If we could just resist the impulse to "do something, anything" when a problem came up, we could save that money with no impact on actual quality of health care.
And yes, we could also make things better while still saving the money. But that's a subject for another post. This one is just on saving the money.
 See http://genomebiology.com/2006/7/2/1
 See my previous post at http://psychohist.livejournal.com/4
 Gary Taubes, Good Calories, Bad Calories, pp 451-452.
"Hey, we can bypass all these utopia-complete political-societal-engineering problems with a simple appeal to INFALLIBLE SCIENCE!" You try to scientize the politics, but you'll end up politicizing the science.
Uh, I didn't mean to glorify science in that manner. But there are cases where scientific research can provide new and useful information. I think everyone is in agreement on that. Warren's original post was saying that and I certainly agree. The remaining 90% of the conversation was all about whether the government or private companies should do the research.
Take for example the issue of Celebrex versus the old school NSAID's like aspirin. I'm not advocating that the government be in charge of developing new drugs like Celebrex. That seems like something that corporations can do much better. But when it comes to evaluating the effectiveness of new drugs I think the government is less biased than, in this case, Pfizer. Sure, the government won't be completely free of bias, but it's got to be better than letting the company that developed the drug evaluate it. That's all I'm saying. We got sidetracked into a discussion of whether the government was "bad" at research or not.
We have the NHTSA to test crash safety and I'm happy about that. It's not like I'm naïve about government pressures, but asking GM to tell us how safe its cars are has got to be worse.
I would note that the FDA regulatory framework helps keep drug trials honest, and that industry shoulders the actual cost of doing the crash tests; arguably both are examples of government regulated industry science, which while imperfect is probably better than giving either the government or industry complete control.
I would also note that just as the drug testing system leaves no one willing to do definitive studies that could show that, say, aspirin is as effective as expensive statin medications in preventing heart attacks and heart attack mortality, the crash test framework accurately accounts only for accident survival, and not accident likelihood.