“Suppose,” columnist George Will approvingly quotes outgoing Secretary of Health and Human Services Michael Leavitt, “buying a car were like getting a knee operation.”

What would that look like, I wonder, if getting a knee operation really were like buying a car?  The consolidation of health care—doctors, nurses, hospitals, drug stores—into three corporate behemoths, which would then be considered too big to go bankrupt?  The aggressive marketing of what the industry wants to sell rather than what people actually need?  Festooning essential surgical procedures with appealing but unnecessary and even unsafe cosmetic options?

Actually, though, the real problem with the Will/Leavitt analysis isn’t the ludicrous choice of the clueless and lumbering auto industry—Ross Perot once said that making GM more responsive was like trying to teach an elephant to tap dance—as a model for restructuring health care.

The problem is that getting a knee operation isn’t, shouldn’t be, and cannot be like buying a car.  And to suppose that it is is to send the conversation about health care off in the wrong direction.

Buying a car is a discretionary purchase.  Even when your old car dies and you need a new one, you have time to make a decision, time to consult Consumer Reports, time to take a test drive, time to compare prices from one dealer to another.  Surgery is most commonly an emergency.

There are only a handful of auto brands to choose from.  But even a medium-size town will have several hospitals and dozens or hundreds of surgeons.

Cars and their components are familiar to almost every driver.  Every surgical procedure is different and even the same procedure affects every patient differently.

Buy the wrong car, and you may be in for inconvenience and frustration.  Make the wrong medical choice and you die.

Where Will and Leavitt go badly wrong, and would lead the nation badly wrong, is to treat health care as primarily an economic dilemma, subject to market solutions.  Will’s lead identifies “health care” as “a nation-ruining issue;” you assume that he will proceed to talk about obesity, environmental carcinogens, pharmaceuticals and the like.  But no: He’s talking about the increase in the share of family income that health care will occupy, the portion of health care dollars spent in the last year of life.  I’ll bet you define Medicare as a program that ensures that older Americans will receive health care.  Will defines it as “a price-fixing system” for medical care and equipment.

The financial issues Will and Leavitt raises are important, even critical: the increase in the number of people covered by Medicare and the decrease in the number paying for it, the increase in what medicine can do and, thus, in the cost of care.

But they are secondary considerations, not secondary in their importance, but considerations that must follow considerations of the essence.  First, what should we be doing, how can we prevent illness before we need to treat it and how should we treat it when it must be treated?  Then, how should we pay for what we should do?  What can we afford?

If, like Will, we ask the financial questions first, we will wind up where Will and his ilk are headed, to the conclusion that we need to provide less heath care to people who can’t afford it so that George Will and most of the rest of us can pay lower taxes.

In twenty years, Will says, the share of household income paid for health care, including taxes that support health care, will increase from 23 percent to 41 percent.  Is that ipso facto bad?  What if that increased cost reflects the cost of developing and distributing treatments for Alzheimer’s disease, AIDS or breast cancer?  What if it pays for increasing the length and quality of life?  What would be a better expenditure of household income than better health?

The horror that Will (in his column, which is linked below) and others display that “nearly 30 percent of Medicare spending pays for care in the final year of patients’ lives” (his emphasis), is a bit like the old searcher’s absurdity that “it’s always in the last place you look.”  Of course it would be better if we invested in health care at an earlier age to prevent catastrophic illness and its high costs at the end.  But Medicare doesn’t even kick in until people reach 65.  Illness, and thus the need for care, increases with age and the approach of death.  One of the most humane developments in health care palliates the pain of the very ill.  So is anybody surprised that health care costs are at their highest at the end?  Should we attempt to predict death a year ahead of time and influence or coerce those about to enter their final years to get a head start on shortening their lives so as to spare the rest of us that 30 percent?

Make no mistake:  We face no more serious challenge than how to pay for the health care we need.  But to suppose that the problem is that we now have too much health care, and that our salvation lies in having less of it, defies the reality of the lives of almost all of us and especially of those who currently can afford almost no health care at all.  And to suppose that the salvation of health care in the United States lies in subjecting it to the tender mercies of the economic modalities that govern the auto industry—making getting surgery more like buying a car—would be like driving in the wrong direction down an already-wreckage-strewn highway.

George Will, “Dr. Leavitt’s Scary Diagnosis”

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