Kevin Drum pushes back

The healthcare front is harder to judge. I agree with Tyler that we waste a lot of money on healthcare, but at the same time, I think a lot of people seriously underrate the value of modern improvements in healthcare. It’s not just vaccines, antibiotics, sterilization and anesthesia. Hip replacements really, truly improve your life quality, far more than a better car does. Ditto for antidepressants, blood pressure meds, cancer treatments, arthritis medication, and much more. The fact that we waste lots of money on useless end-of-life treatments doesn’t make this other stuff any less real.

Matt Yglesias cosigns

I think that’s spot on. The consumer surplus involved in successful medical treatments is gigantic. Indeed, I would say that’s probably a good start at an explanation for whythere’s so much waste. But from a policy point of view this is why I often find myself moored between the impulse to “control costs” and the impulse to “expand access.” What I really want to do is promote good health and there are an awful lot of things we could do to do that at very low cost.

Points well taken and I’ll both backpedal a bit and clarify a bit.

First, yes there are big quality of life improvements that don’t show up in our life expectancy data. Treating pain and emotional distress, of many different forms, is at least as important as extending life and our system has made great strides in doing that.

I want to completely concede that the treatment of pain has improved drastically and that has made a world of difference.

Second, I want to clarify about major breakthroughs. People talk about statins, beta-blockers, chemotherapy, radiation therapy, etc in the treatment of our two major killers, cardiovascular disease and cancer. However, the actual dent these things make in like expectancy is small.

Take statins, which are one of the major weapons in the fight against heart disease. Even the published results in JAMA suggest that the number of people who have to be on statins to prevent a single person from having a single coronary event is between 44 and 258.

However, real world results almost always are worse than trials, not all coronary events are fatal, and the prevention of a coronary event only extends life expectancy if the patient doesn’t die of something else in the mean time. Which makes our frontline weapon not that effective in actually extending life.

Contrast this to penicillin in the treatment of Scarlet Fever. The number to treat is basically one. See a case of Scarlet Fever, administer penicillin. Nearly a fifth of all the people who contract the disease would die from it with no treatment. With treatment almost no one does. The extension in life can be many decades if the disease in contracted in the teens or twenties.

Statins don’t do this. Beta-blockers don’t do this. Chemotherapy in the treatment of cancer doesn’t do this. And, keep in mind these are treatments. Much of our health care dollars are spent on diagnostics. For diagnostics to have any life extending value at all you have to find something, which usually you don’t.

Diagnostics are particularly vulnerable to my critique. People feel reassured when the doctor walks in and says “the MRI was clear.” However, the docs could rephrase this as “I just spent $2000 of your money and its going to make no difference in your health outcome whatsoever, yeah!”

I think I have complained about decision trees before, but people confuse changes in their information set with changes in the state of nature. That a diagnostic procedure comes back negative doesn’t make you healthy, it just reduces your uncertainty about a predetermined fact.

Whatever was true before is true now. We just have more information. Was that information worth $2000? That depends crucially on what we do with it. However, if what we do with it is usually nothing and sometimes to initiate a treatment which will only have an effect in 1 out of 50 cases, then we really have question what we are doing here.