The health-care debate has focused on why medical costs, decade after decade, have increased far faster than other goods and services, as if the laws of inflation don't apply to medical services. Various explanations have been advanced, but three circumstances, and their synergy, have largely escaped attention. The first of these is our society's propensity to pay for things without regard to utility. This is illustrated by what might be called the cataract test.
In the early '90s, while living in Europe, I developed a rare eye disease that among other things led to a cataract in the affected eye. Fortunately the disease had bypassed the other eye. Still, it chastened me to learn that the public health system would not approve a cataract operation in the sick eye: a person with one healthy, cataract-free eye could live more or less normally, and therefore had no entitlement, I was told, to a procedure underwritten by the public sector. The socialized healthcare system covered only the minimum needed for utilitarian purposes.
Years later, once the disease had rendered the affected eye useless in any event, I came to agree with the logic. Being half-blind hasn't diminished my access to a driver's license, for example, in any of the several states I've lived in since returning from Europe.
Be that as it may, the health insurers I interviewed recently all stated that their policies would have covered the surgery — “lens, prosthetic (intraocular) with cataract extraction, one-stage, with second eye healthy,” to use the official terminology. They also stated that they would pay for such exotica as frequent urination and chronic fatigue syndrome, or “yuppie flu” (conditions I myself have “suffered” from, but whose classification as diseases leaves me bemused), assuming “medical necessity” — a very malleable criterion in a society where someone is trying to profit from virtually every facet of medical care.
It is hard to resist the conclusion that health insurance is trending toward covering more and more conditions and procedures, at more and more expense. Those diagnoses and procedures are catalogued in an arcane, periodically revised set of codes known as the international classification of diseases, or ICD. The latest revision of this lengthy roster will make it much longer still, going from 17,500 to 140,000 codes. But Rhonda Buchholtz of the AAPC, medical coding's professional association, says that the new ICD will add only specificity, not new diseases and therapies; the one code for an ankle sprain will become 72, for example.
The revision could perhaps best be described not as an expansion, but as a translation into a more detailed language. More to the point, however, the ICD cannot include procedures that do not yet exist; nor can it anticipate what conditions future medical researchers might “discover” to be pathological. MRIs didn't have codes before their development 40 years ago. (They now have nine.) The ICD's 1965 version made no mention of chronic fatigue syndrome. Medicine is an expanding universe, forever entering new realms.
President Obama's health-care reform act remains an uncertain factor in these developments, but it is difficult to argue that it will shrink the scope of recognized, insurable care. As Marianne Udow-Phillips of the Center for Healthcare Research & Transformation has pointed out, no one can say whether fertility services and eating disorders, to cite two rubrics, will acquire the status of “essential benefits,” as defined by the reform statute, and therefore become legally required elements of health insurance.
We can assume that lobbyists are lining up to tip the decision-making process toward the ailments and procedures they (so to speak) champion. Whether the ultimate decision-maker, the U.S. secretary of health and human services, “will be able to be conservative is a real question,” Udow-Phillips opines. “Politically, it is easier to be more comprehensive when it comes to benefits than to limit the scope of coverage.”
The steep curve of medical inflation thus appears to involve more than the habit of buying. The second factor — this proliferation of innovative procedures and capabilities, and of new diagnoses — is peculiar to only certain sectors, the medical industry among them.
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