Baumol's Curse on Medicine

摘要

A national press worrying everyone over rising health care costs or the inflation-adjusted decline of our science budget is persistent and beleaguering. Government planners are diligently chipping away at growth rates of Medicare and Medicaid while imploring small businesses to expand private insurance—anything to avoid raising taxes. Why budget planners are also shrinking support for the National Institutes of Health is particularly mysterious. Apparently there is feeling in such circles that we do enough science already or that medical science offers no hedge on the future rise of health care costs. Either way, we are charting a course for serious underinvestment in a research enterprise that is intrinsic to our national health.1,2 Narratives documenting the growing costs of health care are all true. As the population expands and ages, much of this rising cost will multiply. In other developed countries where medicine is practiced differently, costs are going up, too, suggesting that choosing different models for delivering health care is not a simple answer to cost containment.3,4 The theses I lay out here are two: First, health care in many respects is a major contributor to the economy and its growth for that reason alone is desirable. Second, the process for choosing or delivering medical therapy as well as discovering truly better therapy, particularly curative therapy, requires more science. Medical research is an authentic response to the recurrent expense of chronic disease. It makes lives better and, not surprising, also helps the economy. The delivery of health care in America is expanding in response to increased public and private consumption. Although the rate of spending has slowed slightly in the past few years,5 part of the reason per capita costs in America are higher than in other countries is because the price of labor and medical services is greater. The contribution of health care to the economy is now north of 16% of the gross domestic product and likely to grow,6 particularly as the population enlarges and rightly demands more access to physicians. One simple and perhaps only short-term answer to more access is to build or modernize more hospitals and clinics and increase the number of physicians. Current evidence suggests both are happening.7–9 Of course, it is unlikely that growth in numbers of physicians by itself will lead to better access to primary care. Much of the graduating physician workforce is already attracted to the subspecialties of medicine for all kinds of reasons that have nothing to do with improving general medical services. In our deep-rooted, fee-for-service culture, no one wants roadblocks obstructing access to subspecialists and, consequently, these specialized niches of applied technology continue to enlarge. Supply creates its own demand, but I wonder whether this feed-forward growth is really so terrible.10,11 Health care is now firmly entrenched in the national economy and employs a large segment of the open workforce for good purpose.6,12 The March 2008 jobs report from the Bureau of Labor Statistics indicated the number of health care jobs rose by 23,000 for a 12-mo gain of 363,000 jobs in this sector, 44% of the total new jobs created in the past year.13 Health care is booming in hospitals and clinics, and the wages from those jobs is fueling growth in disposable and tax spending in the economy. As Richard Cooper of the Leonard Davis Institute for Health Economics (University of Pennsylvania, 2008) recently pointed out to me, “Americans want jobs and they want health care, and the latter begets the former.”12 What economic benefit could possibly come to millions of health care–related workers if the brakes were applied to this enterprise? From medicinal and device manufacturing, clinical facilities construction, acute care labor, nursing home expansion, process improvement, information technology, insurance madness in all its various forms, and administrative compliance,