That Used to Be Us_ How America Fell Behind in thted and How We Can Come Back - Friedman, Thomas L. & Mandelbaum, Michael [99]
As we decide what is affordable and sustainable, particularly care in the last year of people’s lives, decisions will have to be evidence based. “If a medical intervention is going to meaningfully improve or extend life, it should be done,” argues Walker. “If it is not going to meaningfully improve or extend life, then it should not be done.” Today, added Walker, “a lot of it does not pass this test. In fact, some of these high-tech interventions are not even in the patient’s interest.” Individuals and employers ought to be able to spend as much of their own money as they want for medical care right up to the end of their lives, concluded Walker, “but when you’re talking about taxpayer resources, there’s a limit to how much resources we have.”
As part of controlling health spending, we will have to move to a system whereby hospitals and doctors are reimbursed for proven quality and cost-effective services, rather than for procedures alone. This will require a uniform system of health-care information whereby consumers will be able to access a hospital’s or individual doctor’s performance records and prices for different procedures. If I am having a kidney removed, I want to go to the doctor with the best record at the best price—on the basis of criteria established by an independent medical board. Doctors and hospitals who will not participate will not get reimbursement from government programs or private insurers. Consumers also must be exposed to the true costs of their health care, and the differences in quality, so they have incentives to get the best care for the best price. Currently, the vast majority of health-care bills are paid to the provider by the government or private insurance companies on the basis of procedures alone (“Here is how much you get for a colonoscopy”), without reference to outcomes. And most patients never look at a medical bill showing the costs of care. It is hard to bring prices down when you can’t shop.
Moreover, we are all going to have to take better care of ourselves. So much of America’s health-care spending goes to preventable chronic illnesses, such as diabetes and complications from obesity—which the health-care industry then creates all sorts of expensive technologies to mitigate. We simply can’t afford to have so many overweight people, and we certainly can’t afford to have roughly 40 million Americans still smoking, which, according to the Centers for Disease Control and Prevention, still causes at least 30 percent of cancer deaths and 80 percent of lung cancer deaths.
In the cuts in spending that America will have to make, foreign policy cannot be exempt. Defense spending is invariably among the biggest items in the federal budget, and it, too, will have to be reduced. We favor retaining the American military and political roles in Europe, East Asia, and the Middle East, which are crucial for the stability and prosperity of those regions. But America will have to find ways to do these things at a lower cost than in the past.
As Michael argued in his 2010 book, The Frugal Superpower: America’s Global Leadership in a Cash-Strapped Era, the country can no longer afford the kind of military intervention that became common in the post–Cold War era. In that period the United States has conducted military operations in Somalia, Haiti, Bosnia, Kosovo, Afghanistan, Iraq, and Libya—and sent troops to all except the last country. The dispatch