The earlier post, “At what price?”, raised an interesting issue about the cost of cancer therapies that extend life at significant financial and social cost. It echoes a view expressed recently in an article entitled, “Aging Gracelessly: Can the US devise a rational economic model for health care?” It appeared in Acumen: Journal of the Life Sciences.
The article traces data about the rising overall proportion of the economy devoted to health care: 1955, 4% of GDP; 10% in the ‘60s; 13% today; projected 16% by 2010; and 20% by 2040. Some economists argue that this growing expenditure is a drag on overall economic health because it diverts capital from other things like education, infrastructure, and investment in productive capacity. This rise, the author argues, really feeds mainly the “medical-industrial complex.” Nevertheless, it appears the increases will continue.
The article goes on to assert:
“To put it starkly, the United States spends the vast majority of its health care dollars dealing with chronic and degenerative conditions. But the health care system pretends otherwise. The public, press, policy makers, representatives of many pharmaceutical companies, and even many doctors talk about the practice of medicine as if it were still a story of heroic interventions (as it was in the 19th century).
In other words, medical advances of the past achieved dramatic reductions in mortality and morbidity and extended productive life. In contrast, many medical advances today are achieving incremental yet costly progress. From a public cost standpoint (interpreted broadly) there is a big difference between investing in something that results in the elimination of a disease vs. mitigating the condition and turning it into a costly and debilitating long-term proposition. So, preventing or curing cancers broadly and decisively is heroic; but producing incremental improvements in treatment that push more and more people into a state of continuing treatment and care may be humane, but it carries considerable additional cost.
The article also argues that, particularly in the US, life extension does not necessarily mean extension of productive, high-quality life. That is, life has both a span of productivity without chronic debility and then, generally, a period at the end requiring substantial care and maintenance. The dilemma is that the proportion of total years requiring care for chronic conditions compared to “healthy years” in the US is greater than for many other developed nations.
The interesting thing is that in this discussion of the increasing burden of chronic care, cancer is not counted as a chronic condition…not yet anyway. The rising proportion of GDP for chronic disease involves hypertension, mental conditions, respiratory disease, arthritis, heart disease, cholesterol diseases, and diabetes. Evidently for compiling these historical statistics that bring concern cancer is treated as an acute condition. But will that change as cancer becomes more “manageable”? “Survivors” many not be free of disease, but they’re not going to be in immanent danger of death either. If, as it appears some scientists expect. cancer becomes more like other chronic diseases, will cancer gobble-up another couple of percent of GDP? Will the ACS enter the arena of competing for the resources to ameliorate the disease against advocates for various other chronic conditions? Will manageability result in healthy years or additional years of limited function and expensive maintenance?
If medical science results in more chronic-izing, the article predicts a crisis:
It may be that medical science and technology will conquer this dilemma in the next few years. Although the extraordinarily complex biology and physiology of degenerative disease makes that unlikely, a decisive set of breakthroughs that slash the suffering and morbidity from chronic disease cannot be dismissed altogether. But if that does not happen, and if new medical technologies continue to turn acute diseases into chronic conditions, then the problems of financing health care are going to get much worse very quickly. For more than a decade, business leaders and policy makers have tried to reform the mishmash of public and private insurance systems that is U.S. health care finance. But the era of incremental change may soon be over. A break is coming.
Anticipating the worst, the article goes on to consider various options for financing a health care costs if they continue to increase.
All this raises in my mind a number of ACS-related questions. For instance, are we entering a period of some decades when many cancers have a significantly lowered likelihood of mortality but an increased probability of episodic debilitating reocurrences requiring treatment, management and significant expense? If there are true cures on the other side of an unpredictable period of gradual improvements, will we need to prepare a different vision? Can the Society frame for itself and for the public a set of expectations that fit with the reality of cancer’s complexity?
Anybody have any thoughts?