We need to ask hard questions about the dramatic disparities in health care spending that can be seen around the nation.    

Twenty-five years ago, Allen Blume proclaimed a heresy. He stated without equivocation that the phony idealism of the 1960s was in fact a cheap veneer, concealing a new barbarism. He saw the entire elite liberal establishment culture as having a perverted vision. Despite the protestations of diversity and multiculturalism, the truth is we have fallen into an anti-dogmatic dogma which has brought us to an intellectual crisis. “We no longer think about the things we must think about to live truly human lives,” said Blume. We live in an age where confident assertions of moral truths and genuine inquiry are gone. Postmodern liberalism seeks to build a culture of moral relativism, where no one can be hurt by the truth because all truth is relative.

I’m a Blumist. There, I’ve said it. I’ve come out of the intellectual closet. I agree with him when he says that, “The relativity of truth is not a theoretical insight but a moral postulate.” From this vantage point I intend to challenge an array of topics that have become off-limits and unchallengeable in the medical intellectual community. The first dragon I intend to reduce to a piquant snack is that there is some relationship between the amount of money spent on healthcare and healthcare outcomes. You’re invited to this bacchanalia, but be warned: You can bring your own opinions, but not your own facts.

Let’s go to the magic box: Google. Search the internet for “life expectancy by state Medicare expenditures.” Alternatively, you can Google the “Dartmouth Health Atlas” or the “Bill and Melinda Gates Foundation.” It doesn’t matter; they agree on the basic facts:  
1)  Life expectancy in the United States varies widely from state to state; and there is no relationship between what is spent in those states and how long their residents live.
2)  Regions within states vary more than do states with each other. For example, in the state of New York, the counties with the shortest life expectancy spend the most on healthcare.
3)  There is almost no relationship between distance to major medical centers and life expectancy; no one gets lower life insurance rates because they live next door to the Mayo Clinic.

The state of Hawaii has the nation’s best longevity (81.5 years) yet they spend less than a third per elderly person in the Medicare program as the state of New York. Spend less, live longer. Is anyone taking notes? Let’s take a mainland example since some of you are going to say that Hawaiians stay healthy by doing Tai Chi in the morning. I think that’s a bogus argument, but let’s look at South Dakota and Florida. Both are mainland states, both eat beef and have similar adult smoking habits. South Dakotans live longer and spend less than one third per person in the Medicare program than does the state of Florida. Here’s a stat that will blow your mind. If we sent South Dakota the same dollars that we send to the state of Florida for Medicare, the state of South Dakota could pay for all college, roads, prisons and still have a surplus. And don’t think you can explain the longevity in South Dakota by its abundance of great medical centers, “easy lifestyle” (have you been to Sioux Falls in the winter?), a surfeit of doctors or technology.

Of course, once again, we must be geographically specific: we can’t pick on the entire state of Florida because the variations within its borders are unbelievable. Medicare expenditures per person in the Fort Myers area are about half as those in the Miami area. Explain please. By the way, Miami is one of the bellwethers for spending. The Dartmouth Atlas study says that the cost in the best big city in America for longevity – Minneapolis – is less than a third the cost in Dolphin land.

Say what you will, these destinations do not represent areas of medical paradise. But on we work from sun up to sun down, asking no basic questions, accepting the basic dictates that more healthcare is better and that the federal government is here to explain it all to us intellectual toads.

I agree with Blume that the dogma completely stifles questions as to why these facts exist. We are in need of a reunification of the universal desires of all cultures throughout time; we need to return to the discipline of desires, direct ourselves towards goals and ideals, and inculcate feelings of intellectual shame when we fail. All is not relative; there are ideas worth fighting for.

In his critique of Plato’s Dialogues, which is where I first met Professor Blume, he asserted that Socrates challenged his interlocutors to unleash the shackles of prevailing beliefs. Blume thought that attacking convention was the key to deeper truths, and the way to seek our ultimate goal, which is better health and not just new ways of financing the status quo.

Truth is a cruel mistress, giving no quarter, asking no tribute except respect. The endless chattering of our governmental machinery with their seven-second sound bytes and simplistic syllogisms seems positively Swiftian. We need a Virgil to guide us through this intellectual inferno.



# Emergency PhysicianHoward Swidler 2012-08-16 02:16
If you want insight into the cost differences and why they have no effect or even negative effects (more money spent for worse outcome). I suggest you begin by considering the sophistication of the local vendors of care in terms of there ability to focus on profit over outcome. Florida is a haven for exploitation of the system ranging from outright fraud and abuse, to "well run" (from a business perspective) medical practice and supporting industry. High cost comes in two flavors, Old school was just independent doctors doing unneeded procedures, New school costs are seen in those areas that have "evolved" in the "medicine as business" model. it comes in many varieties. But the bottom line is they have learned how to extract megadollars from the system in some niche area. sometimes "legally" and sometimes not. Make no mistake. their methods will continue to spread. There is likely already a conference telling you how to cash in for more bucks in your chosen niche. And if you already have something working, a larger entity might interested in acquiring it for their equity partners and leveraging it even further.
# The InevitableReflective 2012-08-18 12:07
What is your opinion of the argument that some health disparities are inevitable based on socioeconomic class?
# responsethe author 2012-08-28 09:43
My thanks to those who wrote in. Now I know that at least two people are reading the column. Dr Swidler raises an interesting point and that is more people are getting rich off disease than dying from it. If you pay a doctor to order tests and do things...they will do things that till we stop them. This is human nature. OK, I get that but it is much more complex than that. This does not explain hugh state by state variations. I think it is multifactorial. This is a cultural belief problem. People in Florida do not see themselves as a part of the cosmos. No matter how much money is spent they will not have a meaningful life or dignified end of life until we learn to deal with death as a normal part of life. You can not escape the cycle. Do you realy want to die in a hospital vomiting from radiation and chemotherapy or at home with people you love. Is CHF really better in the hospital? We need the national conversation for the largest part of the GDP. That's what presidents are for in my opinion. As to two levels of health care I think there will always be some advantage to being rich. But that is for only a minor number of things. Rich people do better because, as a group, they make better life choices. When are we going to realize that we are the masters of our own fate. High quality lives are most often the results of excellent attitude,thinki ng about issues and a belief in something. Greg
# If we're being completely honest.Klingon Empire 2012-08-29 09:58
"We are in need of a reunification of the universal desires of all cultures throughout time..." That's going to be a very short list.

To paint with a very broad brush, it's a given that both the quality of life and life expectancy of a state full of Lutheran farmers is going to be markedly different than that of that of a state full of tequila and percocet swilling Jimmy Buffet fans who used to live in New York city. Or perhaps the level of health care spending unleashed by physicians in Florida is related to the population of suit-wearing land sharks there.

Or perhaps the bottom line is that while the presence of health care spending seems to have little effect, its absence (perhaps past a certain point) has a dramatic one. If this is in fact the case, living the next decade or two under the affordable care act will surely enable us to find out where that point is through a process of trial and error. Just make sure you have really good malpractice insurance for the trip.

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