What Cannot Be Said on Television About Health Care

“There are 400,000 words in the English language, and there are seven of them that you can't say on television.”¹ said George Carlin. For many years, health care faced the same inhibition; certain words could not be uttered in public about health care. Rationing was one such word. In the 1980s and 1990s, commentators who discussed rationing, such as Callahan and Lamm, were publicly censured for their views.^{2 - 3}

The words that are used and the words that cannot be used in public reveal a tremendous amount about how people think and act, about what is assumed, and what we aspire to.⁴ Usual phrases express the conventional wisdom, what the public accepts reflexively, without explanation, justification, or challenge. Conversely, those words that cannot be said on TV reveal what many refuse to accept or believe. Words that should not be uttered in public—but still may be used by the unenlightened—reveal the subtle insights of perceptive social commentators.

Today, the United States is undergoing a significant change in the language of medicine. Words that once were said about the health care system reflexively, used to be assumed, increasingly cannot be said in public, or if uttered have to be seriously qualified. Unlike Carlin's words, it is not that words about health care are profane or offensive, it is that they are increasingly untenable and unbelievable. Saying them suggests the speaker is out of touch with reality; they are the equivalent of former President George H. W. Bush's shock at the supermarket checkout scanner.⁵ They are a sign that the speaker fails to appreciate the experiences of the average American who interacts with the health care system.

Some of these changes seem solidified and have become the norm. Others are still in evolution; while they should not be said on TV, commentators are not yet consistently censured for uttering them. But all suggest serious movement in how health care is perceived, movement that portends willingness of more Americans to abide significant changes in the system. There are 3 phrases that should and can no longer be said about the US health care system without qualification, embarrassment, criticism, or even denunciation: “The United States has the best health care system in the world,” “Health care is special,” and “New is better.”

It used to be an accepted trope for US politicians to puff up their chests and pronounce that the United States had the best health care system in the world. Simultaneously, they would vehemently denounce as unpatriotic anyone who hinted that there were serious problems with the US health care system. In 2001, while testifying to a House subcommittee, I personally experienced a congressman's wrath when I noted that many Americans with colorectal cancer were not getting appropriate adjuvant chemotherapy. Incredulous, he demanded to know if “God forbid, you should ever have cancer, where [besides the United States] would you choose to be treated?”⁶

Politicians could say such things because Americans believed them. Even if people somehow knew there were problems, there was a sense that the United States had the best—that those who were rich and could afford anything or were admitted to one of America's great teaching hospitals were getting the best health care available anywhere in the world.

This is no longer true. Many no longer believe the United States has the best health care system in the world.⁷ The statistics are damning. The United States has the most expensive system, by far. In 2005 health care cost more than $6000 per person or in excess of 16% of the gross domestic product (GDP).⁸ The nearest rival, Switzerland, spends $4077 per person per year, or 11.5% of its GDP (in purchasing power parity).⁹ Norway spends $3966 (9.7% of GDP); Germany, $3043 (10.6% of GDP); and South Korea, a mere $1149 (8.2% of GDP).⁹ However, Americans are increasingly aware that all of this money is not buying very much. Life expectancy in the United States is 78 years, ranking 45th in the world, well behind Switzerland, Norway, Germany, and even Greece, Bosnia, and Jordan.¹⁰ The US infant mortality rate is 6.37 per 1000 live births, higher than almost all other developed countries, as well as Cuba. Even for white individuals, the numbers are not world class—5.7 infant deaths per 1000 live births—more than double the rate in Singapore, Sweden, and Japan.⁹ Even at the individual hospital level, Americans are realizing the care they receive is not of the highest quality. The idea put forth in the Institute of Medicine report To Err Is Human that 100 000 Americans die each year from medication errors in the hospital has taken hold in the public consciousness as emblematic of the problems with the quality of health care.¹¹

Furthermore, Americans are becoming aware that in such an unreliable system even money cannot guarantee outstanding care. Berwick, one of the nation's leading experts on quality of care, recounted the multiple near misses and mistakes his wife experienced while receiving care in some of this country's great hospitals.¹² Americans are increasingly aware that structural and systemic problems—lack of electronic medical records, computerized physician orders, and coordination among various clinicians and health care systems—mean that these problems affect rich and poor alike, that people cannot really buy their way out of unsafe and unreliable care no matter how much money they have. Paying more does not necessarily protect a person from errors in drug orders, undergoing surgery on the wrong leg, acquiring infections by clinicians' failure to wash hands, or other errors. Increasingly, more Americans recognize that it is no longer true that the rich and those admitted to the “best” hospitals can be assured of getting the best care in the world.

Within the last few years, the tipping point has been passed. Something has radically changed when the New Yorker claims the system is a mess¹³ and when UnitedHealthcare, a corporate pillar of the status quo, opens an advertisement in the Wall Street Journal by boldly stating that

The health system isn't healthy. There's no denying it. A system that was designed to make you feel better often just makes things worse.¹⁴

The US health care system is considered a dysfunctional mess. Conventional wisdom has been turned on its head. If a politician declares that the United States has the best health care system in the world today, he or she looks clueless rather than patriotic or authoritative.

For decades it was accepted that health care was special. Indeed, it was so special it could not be considered a usual good or service to be traded on the market for other goods. As Daniels, a leading bioethicist, once argued, “A theory of health care needs should . . . illuminate the sense in which many of us think health care is special and should be treated differently from other social goods.”¹⁵

To many, the specialness of health care meant that cost should not be a consideration in care. Ethical physicians could and should not consider money in deciding what they should do for sick patients. Patients were to receive whatever services they needed, regardless of its cost. Reasoning based on cost has been strenuously resisted; it violated the Hippocratic Oath, was associated with rationing, and derided as putting a price on life, akin to the economist who knew the price of everything but the value of nothing. Indeed, many physicians were willing to lie to get patients what they needed from insurance companies that were trying to hold costs down.^{16 - 17}

The tipping point came when the media began reporting that the high cost of pharmaceuticals forced some elderly to choose between drugs and food.¹⁸ Health care actually was being traded off against other goods both at the individual and social level. The implication was that for Americans, health care did not necessarily seem so special; other essential needs—food, housing, or heating—could be just as special. The same phenomenon began to play out in state budgets. Increasing costs of Medicaid and health insurance premiums for state workers meant cuts in Medicaid's discretionary services or, more commonly, in other state services, especially primary and secondary education and support for state colleges and universities.¹⁹

Americans began to realize that, as the economists would say, spending on health care has opportunity costs. Too much money spent on health care reduced the ability to obtain other essentials of human life as well as some goods and services not essential to life but still of great value, such as education, vacations, and the arts. Indeed, experts in the social determinants of health emphasized that many of these other factors, from income to education, were integral and perhaps even more integral than health care services for improving health outcomes. When health care began compromising access to other important goods—food, heating, and education—it ceased to be so special it was beyond cost.

Today, saying that health care is so special that its cost is irrelevant serves to discredit the source. A New York Times reporter learned this lesson the hard way when he praised a study that claimed by “virtually any commonly cited value of a year of life, we found that if medical care accounts for about half the [6.97 year] gain in life expectancy [since 1960] then the increased spending has, on average, been worth it.”²⁰ In response, the reporter “received about 500 e-mail responses from readers, and the most common reaction was a version of a simple question: ‘Why do Americans spend so much more than folks in most other developed countries while getting worse results?’”²¹

Replacing the notion that cost is irrelevant is the notion of value. Just as consumers ask whether a car or a computer is worth the cost, health care consumers are beginning to ask whether a health care intervention is worth the cost. Increasingly, health care needs to be measured by the same metrics as other goods and services—cost, quality, benefits, and value. It can no longer claim to be treated differently from other social goods.

Americans are enamored with technology, especially health technology. The US Food and Drug Administration has been urged to use surrogate markers to approve drugs and medical devices faster so they can help sick patients. Not only is the United States an early adopter of new health care technologies, many physicians are early “proliferators” of technological innovations. As shown with drug-eluting stents, physicians not only rapidly used these devices for patients who fit the clinical indications for which stents were shown to be clinically beneficial, but nearly 60% of stents were implemented for off-label indications, ie, use in patients with lesions for which the stents have not been shown in clinical trials to be beneficial.²² Similarly, approximately 1 in 7 prescriptions is for off-label use of drugs not supported by published evidence.²³

Increasingly, Americans are beginning to be skeptical about whether new health care technologies are better. The tipping point probably came with the withdrawal of rofecoxib from the US market. Today, the list of drugs and technologies for which new might not be better (and may be even worse) has expanded rapidly: postmenopausal hormone therapy, bare-metal stents, megadose antioxidants, selective serotonin reuptake inhibitors for adolescents, Swan-Ganz catheters, gabapentin for bipolar disorder, erythropoietin for anemia, and the list goes on.

Unlike the other phrases, it is still possible to say on TV that “new drugs and health care technologies are improved and better.” But that phrase is more frequently countered with examples, more frequently challenged, and less readily believed without qualification. However, it will be impossible to eliminate this notion from the US lexicon; pursuing what is new is constitutive of the American ethos. The United States was built on the new continent and dedicated to a new ideal of inalienable rights, and Americans readily affirmed the New Deal, the New Frontier, and the New Morning in America. Nevertheless, Americans do seem to be less willing to automatically embrace new health care technologies just because they are new. Instead, many are more likely to read the restrictions, accept that the provisos have merit, and question the true value of the new interventions.

The evolution in what can and cannot be said on TV regarding the US health care system confirms and reinforces that there is an important change occurring in how many Americans view the health care system. The change in language suggests Americans now recognize that the system has deep structural problems. While this recognition is no guarantee of change, it does constitute a critical precondition for comprehensive reform of the system. Reform cannot occur without acknowledging that there is a problem. The next step is for the public to see a solution that they think offers a realistic chance of making the system better.²⁴ Maybe this will become something that not only can be said on TV, but certainly will deserve to be emphasized.