The longer I look at health care issues, the more I am convinced that there is hardly any point in discussing them, because none of us knows what we are talking about. Literally.
Chris and I just returned from a long road trip to El Paso, to spend a weekend celebrating my dad’s 80th birthday. It was two days driving out, two days back. We listened to a fair amount of NPR news programming along the way, and so got an earful of the controversy over the new guidelines for mammograms for women under fifty. In hours of talk I heard only one number that caught my attention, mentioned in passing, stating that for every 1900 women screened one case of cancer will be detected.
I immediately wanted a second number, namely the cost of a mammogram, but never heard it. Just to help with some level-setting, I assumed that it would cost $1000, not uncommon for a medical procedure. That would mean that it would cost $1.9 million to detect that case. It sounds like a lot, but I wasn’t sure how to think about it. And I had my netbook with me, so at the motel room that night I decided to spend a little time doing some research.
The first thing I found was an article somewhere that the one in 1900 number means that one case is discovered if 1900 women are screened annually for ten years, meaning it takes 19,000 scans to find that one case, ten times what I originally thought. So I was alarmed—$19 million dollars to detect a single case of cancer?
For an uninsured patient, typical full-price cost of a mammogram ranges from$80 to $120 or more, with an average of about $102, according to Blue Cross Blue Shield of North Carolina. Some providers charge more, and some offer an uninsured discount. For example, at the Kapiolani Medical Center in Aiea, Hawaii, where the full price is about $212, an uninsured patient would pay about $127 to $148.
Ah, mammograms cost roughly $100. Assuming that, it costs $1.9 million to detect a case of cancer. Is that a reasonable cost for society to bear? I don’t know, but it could make sense when spread across the individuals involved—that is, any given woman might be glad to pay $100 each year for the peace of mind a scan would provide, even if there is only a one in 19,000 chance the scan will turn up something.
But then I read further down the page, which contains posts from people giving brief descriptions of what their own mammograms actually cost them, and was dismayed again. First, because the actual costs incurred ranged between about $750 and $2500, making $1000 a reasonable assumption again ($19 million per case detected).
Second, the comments from women involved made it clear that even a few hundred dollars was more than they were willing to pay out of pocket to cover the very small chance that they had cancer. This may sound miserly and unreasonable, but one of the few things I learned from the hours of radio discussion was that the early detection which a mammogram provides may not actually be worth that much—there is a natural assumption that early detection would lead to more effective treatment and a better chance of survival, but this turns out to not be true.
So, where did this all leave me? Mostly confused. Ten thousand dollars over ten years seems a lot for an individual to pay to find out if she is the 1900th woman, and nineteen million dollars seems high for society (or an insurance pool) to pay to find that one woman. One thousand dollars over ten years seems like not so much—at least it seems like a woman could fairly be expected to pay that out of her own pocket to put her mind at ease—but it would take socialized medicine to get the cost down that low, in which case she wouldn’t be paying out of her own pocket, and society would be paying $1.9 million to find her, still a high price.
It seems like an impossible question to discuss, and yet I am reminded that one group of people does discuss it, namely the plain people who eschew insurance and depend on community support to pay for medical expenses which are beyond the individual’s ability to pay. A small Amish or Mennonite community would be instantly bankrupted if they adopted the modern world’s hands-off attitude on how health care should be allocated, and so I assume that these issues are faced honestly and squarely on a regular basis.