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At Home with Harvard

At Home with Harvard: Health Care in America

11.16.20


This round-up is part of Harvard Magazine’s series “At Home with Harvard,” a guide to what to read, watch, listen to, and do while social distancing. Read the previous selections, featuring articles about climate change, racial justice, alumni musicians, and more, here.

Healthcare policy—covering the millions of Americans who are still uninsured, and reducing the costs of care for everyone—is a major priority area for the incoming Biden administration. In this week’s At Home with Harvard, we’ve rounded up Harvard Magazine’s most germane past work on the crises in American health care—made all the more urgent by a devastating pandemic. 

 

When healthcare economist David Cutler began examining why the United States gets so little benefit relative to spending on what is widely regarded as the best health care in the world, he found that high costs are driven by administration. The complexity of the U.S. system makes it very expensive—and also creates opportunities for price gouging, whether in pharmaceuticals or in the cost of hospital care. Although Americans “don’t see the doctor any more often than Canadians do,” writes Cutler in “The World's Costliest Health Care,’ a damning profile of the U.S. healthcare system, they receive four times the number of MRIs per capita. And they get less routine care than they should. Given the rising share of U.S. healthcare costs as a percentage of GDP, Cutler’s work is a must-read. 

Some social programs more than pay for themselves, especially when children are the beneficiaries. So finds professor of economics Nathaniel Hendren and other young scholars who have begun studying the long-term benefits of expanded Medicaid programs and spending on K-12 education, as we covered in a recent story, “Welfare’s Payback.” But Hendren also identifies a structural problem with the payback of such programs: while the spending takes place at the state or local level, the benefits, which accrue in the form of higher income-tax revenue, generate returns at the federal level. This kind of comprehensive analysis allows legislators to think beyond the specifics of spending—to the de-incentivized structure of the nation’s social programs and how that might be fixed. 

~Jonathan Shaw, Managing Editor 


David Cutler

David Cutler joined Harvard Magazine’s podcast, “Ask a Harvard Professor,” earlier this year to talk through everything wrong with the U.S. healthcare system. “There is no reason why we should have a system that says depending on exactly who your employer is, this is what you have to do to get a knee replacement, or a hip replacement, or an MRI, or whatever else it is,” he told me and my colleague Jon Shaw. I couldn’t recommend this episode more for a clear-eyed discussion of fixing American health care. 


Image by iStock

I’ve written a lot about healthcare economics over the years at Harvard Magazine: “The Changing Consensus on Healthcare Cost-Sharing” and “Are Hospital Pay-for-Performance Programs Failing?” cover how, to the surprise of economists, programs promoted by the Affordable Care Act that are designed to help reign in healthcare costs may not be working as expected. In “A New Challenge for Antitrust,” I covered how the increasing monopolization of health care—more and more hospitals are owned by the same investors—threatens to drive up healthcare prices for patients. 

~Marina Bolotnikova, Associate Editor

  

I love this feature profile of Harvard Medical School professor Atul Gawande as a “slightly bewildered” surgeon and a writer whose mind “gravitates toward interesting conundrums,” as one New Yorker editor put it. In both pursuits, he finds himself confronting the unknown. Former Harvard Magazine writer Elizabeth Gudrais weaves together Gawande’s twin professions here, showing him agonizing over patients in the operating room and words on the page. She tracks how the MacArthur-winning author of The Checklist Manifesto and numerous other books and magazine articles came to be a literary voice of questioning and critique in the medical profession. “Gawande is happiest when he has a lot going on,” writes Gudrais. Read about the rest of it here.

A few years ago, Harvard economist David Cutler coauthored a study that gave a name to the doctors who drive up the cost of medicine by over-treating the critically ill: “cowboys.” As writer Zara Zhang explains in this 2015 story, cowboy doctors’ insistence on extra procedures that offer little or no marginal benefit springs from their self-perception as interventionists. Cutler tells Zhang, “I think some doctors are saying: ‘I just can’t accept that this patient is dying and there’s absolutely nothing I can do. I’ve got to do something.’” One other interesting tidbit: according to the study’s data, cowboy doctors tend to be male, and non-specialists, and to congregate in southeastern states. Their reluctance to consider palliative care wasn’t linked to a desire for more income, but instead to a lack of penalties for unnecessary care. “The healthcare system’s current incentives,” Zhang wrote, “often do not prompt doctors to ask the right questions, such as whether a proposed treatment truly benefits the patient.” 

~Lydialyle Gibson, Associate Editor 

 

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