The health of nations: instead of forcing seniors into HMOs, how about forcing them to exercise?

• Author: Longman, Phillip J.

TO GET AN IDEA OF HOW WILDLY ineffective our health-care system is, consider this: The United States spends roughly $4,500 per person on health care each year. Costa Rica spends just $273. That small Central American country also has half as many doctors per capita as the United States. Yet the life expectancy of the average Costa Rican is virtually the same as the average American's: 76.1 years.

How can that be? According to public health researchers, the biggest reasons are behavior and environment. Costa Ricans consume about half as many cigarettes per person as we do. Not surprisingly, they are four times less likely to die of lung cancer. The car ownership rate in Costa Rica is a fraction of what it is in the United States. That not only means that fewer Costa Ricans die in auto accidents, but that they do a lot more walking, and hence they get more exercise. Thanks to a much lower McDonald's-to-citizen ratio, the average Costa Rican thrives on a traditional diet of rice, beans, fruits, vegetables, and a moderate amount of fried food--and therefore enjoys one of the world's lowest rates of heart disease and other stress-related illnesses.

The simple comparison between the health of Costa Ricans and Americans suggests a whole new way to think about how to fix America's increasingly dysfunctional health-care system--a system that these days seems to combine spiraling costs, declining coverage, and growing dissatisfaction with the quality of care. But instead of offering new ideas, both political parties in Washington are stuck in a hopeless rut, each trying to hawk plans that essentially expand the current system.

The battle over a Medicare prescription-drag benefit is a classic example. In March, President Bush unveiled a plan to provide partial drug discounts to all seniors, but full discounts only to those who leave traditional "fee-for-service" Medicare and join an HMO. Democrats derided the plan as a stealth attempt to "privatize" Medicare and argued instead for a much more generous plan that would give full discounts to all seniors, including those who remain in traditional Medicare.

Neither party seems to get it. Simply adding an expensive new benefit to a Medicare system whose costs are running out of control, as Democrats want to do, is fiscally irresponsible. Republicans, however, are deluded if they think funneling the elderly into HMOs will do much to cut health-care costs for long--HMO costs in the private sector are soaring. Moreover, when the Clinton administration experimented with a program to lure seniors into HMOs (Medicare+Choice), the result was chaos: Many HMOs went broke, others raised premiums, cut benefits, shifted costs, or simply dropped hundreds of thousands of seniors.

Both parties should pause and reflect. For all the additional money we're throwing into medicine, Americans aren't getting much healthier. Maybe it's time to try a different approach. The biggest opportunities for improving the health of Americans--and restraining health-care costs--lie in keeping people healthy, rather than treating them once they become sick. So instead of simply adding more benefits to a health-care system that is already financially unsustainable, or using new benefits to herd people into HMOs, why not offer a more sensible deal: Bribe people into taking better care of themselves. For instance, why not offer seniors who exercise bigger drug discounts than those who don't?

This may sound radical, and it is. But the more Americans learn about the costs and failings of contemporary medicine and the extraordinary benefits they can reap from simple behavioral changes like exercising, the more such plans will begin to make sense.

Clean Living

To understand the value of this approach, it is important to clarify a common misperception about health care. During the 20th century, the health and life expectancy of the average American improved dramatically. A child born today can expect to live a full 30 years longer than one born in 1900. Improvements in medicine, however, played a surprisingly small role in this achievement. Public health experts agree that it contributed no more than five of those 30 years.

This may seem counterintuitive given the attention society pays to medical breakthroughs. But the changes in living and working conditions over the last century are the real reason. American cities at the turn of the last century stank of coal dust, manure, and rotting garbage. Most people still used latrines and outhouses. As recently as 1913, industrial accidents killed 23,000 Americans annually. Milk and meat were often spoiled; the water supply untreated. Trichinellosis, a dangerous parasite found in meat, infected 16 percent of the population, while food-borne bacteria such as salmonella, clostridium, and staphylococcus killed millions, especially children, 10 percent of whom died before their first birthday.

During the first half of the 20th century, living and working conditions improved vastly for most Americans. Workplace fatalities dropped 90 percent. This, combined with public health measures such as mosquito control, quarantines, and food inspections, led to dramatic declines in premature death. In 1900, 194 of every 100,000 U.S. residents died from tuberculosis. By 1940, before the advent of any effective medical treatment, reductions in overcrowded tenements combined with quarantine efforts had reduced the death rate by three-fourths.

As the century progressed, medical care grew enormously more sophisticated and effective, particularly in managing pain and preventing sudden death from traumatic injury, infection, and heart attack. But the overall gains to public health remained modest. The greatest gains came from strategic vaccination campaigns, which have virtually eliminated once-common diseases, including diphtheria, tetanus, poliomyelitis, smallpox, measles, mumps, rubella, and meningitis. But even these triumphs involved treating people before they became sick. Modern medicine's ability to actually cure people is quite depressing. The consensus estimate, accepted by the Centers for Disease Control (CDC), is that medicine has contributed just two of the seven years in added life expectancy achieved since 1950.

The reason is that, strictly speaking, medicine doesn't "save" lives, but extends them. If you're like my son, who spent the first 60 days of his life in a neonatal intensive care unit, medical intervention could extend your lifespan 90 years or more--but that number diminishes if you're 50, much more so if you're 90.

This gets at an important truth about the role medicine plays in public health--it is concentrated primarily on the elderly, who consume about 38 percent of all health-care dollars, yet account for just 12.4 percent of the population. By definition, the elderly have fewer years of life to extend than the young. This simple fact goes a long way toward explaining medicine's modest role in improving life expectancy: It cannot stop aging.

Sure, many best-sellers and newsweeklies tout the "longevity revolution" prompted by advances in cutting-edge medicine. But overall longevity is due more to dramatic reductions in infant mortality, which allow more people to grow old, than to modestly extended lives among the elderly. Since 1950, life expectancy at 65 has increased by just 3.45 years; among women over 65, it has actually declined slightly since 1992.

Domino's Theory

Another reason for the medical system's limited role in extending life is that...