New York Times Opinion

By Paul Krugman-Opinion Columnist

Last Friday the Medicare trustees released their latest report on the system’s finances, and it contained some unexpected good news:Expenditures are running below projections, and the Hospital Insurance Trust Fund won’t be exhausted as soon as previously predicted.

But one important reason for this financial improvement was grisly: Covid killed a substantial number of Medicare beneficiaries. And thevictims were disproportionately seniors already suffering from severe — and expensive — health problems. “As a result, the survivingpopulation had spending that was lower than average.”

READ MORE

Weathered, wiry and in his early 60s, the man stumbled into clinic, trailing cigarette smoke and clutching his chest. Over the previousweek, he had had fleeting episodes of chest pressure but stayed away from the hospital.

“I didn’t want to get the coronavirus,” he gasped as the nurses unbuttoned his shirt to get an EKG. Only when his pain had becomerelentless did he feel he had no choice but to come in.

In pre-pandemic times, patients like him were routine at my Boston-area hospital; we saw them almost every day. But for much of thespring and summer, the halls and parking lots were eerily empty. I wondered if people were staying home and getting sicker, and Iimagined that in a few months’ time these patients, once they became too ill to manage on their own, might flood the emergency rooms,wards and I.C.U.s, in a non-Covid wave.

That does not mean that all the care provided to dying patients — or to any patient — is valuable. Another study finds that high end-of-life spending in a region is closely related to the proportion of doctors in that region who use treatments not supported by evidence — in other words, waste.

“People at high risk of dying certainly require more health care,” said Jonathan Skinner, an author of the study and a professor of economics at Dartmouth. “But why should some regions be hospitalizing otherwise similar high-risk patients at much higher rates than other regions?”

There were two areas where the United States really was quite different: We pay substantially higher prices for medical services, including hospitalization, doctors’ visits and prescription drugs. And our complex payment system causes us to spend far more on administrative costs. The United States also has a higher rate of poverty and more obesity than any of the other countries, possible contributors to lower life expectancy that may not be explained by differences in health care delivery systems.

Just because other countries use the hospital more doesn’t mean that every hospitalization in the United States is appropriate. Jonathan Skinner, a professor at Dartmouth, who has studied patterns in health care use in the United States, noted that there probably is money to be saved by eliminating some of the extra scans and operations that are much more common in the United States than elsewhere.

You might think that once drugs, devices and medical procedures are shown to be effective, they quickly become available. You might also think that those shown not to work as well as alternatives are immediately discarded.

Reasonable assumptions both, but you’d be wrong.

Instead, innovations in health care diffuse unevenly across geographic regions — not unlike the spread of a contagious disease. And even when studies show a new technology is overused, retrenchment is very slow and seemingly haphazard.