Shannon Brownlee, a senior vice president at the Lown Institute in Brookline, Mass., is a journalist and writer whose work has appeared in such publications as The New York Times, Slate, The Atlantic, The Washington Post, BMJ, and many others. She is a former senior writer and editor atU.S. News & World Report. David Leonhardt, a New York Times economics correspondent, cited her eye-opening examination of the harms of excess medical care—Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer—as the best economics book of 2007.
Brownlee received a master’s degree in marine science from the University of California, Santa Cruz. She is currently a visiting scientist at Harvard School of Public Health. She spoke with us in advance of a talk about the future of the U.S. health care system on Feb. 23, 2017, at the UC Berkeley School of Public Health, co-sponsored by the Graduate School of Journalism and Kaiser Permanente.
What is the relationship between the long-term rise in health care costs and people’s wages?
We call health care “the hidden thief” because it is one of the main reasons that average people have not seen their wages go up appreciably in the last 25 years. Productivity has been rising, and part of that productivity ought to show up in worker’s wages. But health care costs have been rising faster than the rest of the economy, and they have sucked up all the money. Workers who have health insurance through their employers don’t perceive it, because their employers pay most of the insurance premium. They don’t think about where that money for health care is coming from. It isn’t coming out of the CEO’s pocket, it’s coming out of their future wages. And people in the true middle, with a median salary—and the median household income is $65,000 for a family of four—what’s happening to them? They have jobs, they often work two jobs, yet their standard of living is no better than that of their parents. I’m not saying that the individuals who work in health care are thieves. But the sector as a whole has managed to get a death grip on the rest of the economy, and it is workers who are suffering the most.
What is the long-term impact of that?
It’s as if health care is robbing us of the American dream, which is that you’ll work hard and that you’ll have a better life than your parents did. It’s contributing to inequality because the relative impact of rising health care costs is much greater on people in the median income range than it is on people in the upper class. It is also making it harder for employers to hire new people. One of the things they consider is not just the wages but also the benefits, and health care is this really unstable, unpredictable cost for employers. In order to invest in the total cost of new employees, employers have to think long and hard about those total costs. If you don’t hire people, they don’t have jobs. And so rising health care costs have been contributing to sluggish job growth and stagnation of wages, which is part of the rise in income inequality, and many people don’t know it because it’s invisible.
We hear a lot about the epidemic of opioid abuse in the U.S. Is this stagnation of wages and increase in inequality part of what’s behind the situation?
Well, we can trace a great deal of what’s been happening to a couple of things. There’s the marketing by companies making these drugs, and there’s also a level of despair people are feeling, in part, some experts believe, because of wage stagnation and loss of jobs. What’s shocking is that despair is also contributing to lower average life expectancies, in part because of the suicides and drug overdoses that are associated with it. For the first time in American history, many people are looking at having shorter lives than their parents did. White Americans who do not have college degrees—middle-class whites, both men and women—are experiencing declining longevity. This is not supposed to happen. The richer a country gets, the longer people are supposed to live, yet what we’re seeing is that a significant part of our population isn’t experiencing that. We have a growing economy again, and yet there are still a hell of a lot of people left out of that economy—and these are people who would like to be working.
What’s the media's role in this dynamic? Are there things journalists should be doing that we haven't been?
The media’s role is to stop acting like every new thing in scientific research and advanced medical technology is going to save us. This is an ongoing failure in the media, driven I think by editors who want to put happy health care news on the front page. We suffer from technology fetishism. The tragedy is, there’s a lot that’s new in health care that isn’t shiny, that isn’t technological. Like new models for paying for health care that allow primary care practices to do a better job of caring for the sickest patients. Models that don’t require a lot of doctors, but more nurses and medical assistants, who are available on the phone, who make house calls.
The other thing journalists really have to understand is the corruption in health care. There is an enormous amount of money swashing around in this system, and that has normalized corrupt behavior and conflicts of interest. Taking what amounts to a kickback (from pharmaceutical companies and medical device makers, for example) has been normalized in medicine, and reporters have to see the pervasiveness of that. Rather than treating each case of a cardiologist who implants too many stents as a bad apple, they need to understand that that’s institutionalized behavior—every hospital wants its cardiologists to put in as many stents as possible. I think health and medical reporters have woken up to how big the dysfunction in this system is, and now they must also recognize the depth of corruption.
What can people do on their own, as health care consumers?
They can ask questions. In the clinic, in the doctor’s office, in the hospital, there’s a series of questions that families and patients need to ask about the medical decisions they’re facing, whether it’s “Should I have a knee replacement?” or “Should I have my baby in the hospital or with a midwife at home?” And the questions are simple: What are my treatment options? What are the possible benefits and what are the possible harms of each alternative? How do those possible outcomes apply to me and my situation, and what if I don’t get treated at all for this? And how much does it cost, and how much of the bill will I have to pay? People are being hit with really shocking out of pocket costs. If you’re going in for a manicure you’re going to ask the price. If you are buying a car, you ask the price. We don’t ask these kinds of simple questions about health care.
What does asking those questions do?
It can open up a conversation with the health care professional taking care of you, whether it’s a surgeon or primary care doctor or nurse. These conversations lie at the heart of really good health care. Now, that’s not to say every time you get treated there has to be a long discussion. If a 60-year-old woman comes into the ER with a heart attack, doctors and nurses immediately get to work making sure they protect that person’s life and get the blood flowing to the heart muscle again, no questions asked, or at least very few. But many decisions should depend not only upon what the patient needs, but also what difference the treatment will make in his or her life and whether or not the potential downsides of the treatment, and there are always downsides, are worth risking. The only way the people who care for us can know what matters to us is through a conversation about the treatment choices and about our desires and goals for our lives.
Also see Why American Health Care Is Sick.