The U.S. has a lengthy history of government involvement in the health domain. Legislation was enacted in 1798, authorizing the provision of medical care for merchant seamen and for establishing the U.S. Marine Hospital. By 1799, federal state cooperation produced efforts to enforce quarantine laws to stem the spread of infectious diseases, e.g., cholera and yellow fever. The 20th century entailed major achievements including creation of the NIH and efforts to improve the health workforce. The Roosevelt Administration in the 1930s and 1940s reflected efforts to expand health insurance coverage for the entire population of this country. By the early 1990s, it became evident that the major focus should not be only on insurance coverage, but also on improving health care quality and controlling a steady rise in the growth of health care costs.
Unfortunately, this last item does not always attract the attention it warrants in the policy arena. Overall, the nation has a debt of $34 trillion. It grows each year because revenues are less than expenditures. According to a report issued on February 15, 2024 by the Government Accountability Office (Report GAO-24-106987), when the government spends more than it collects in revenue, it borrows to finance the resulting deficit by issuing debt to the public. The fiscal year 2023 deficit was $1.7 trillion, the fourth year in a row above $1 trillion. The deficit is composed of two parts: the primary deficit, the gap between program spending and revenue, which was about $1 trillion in fiscal year 2023. Also, net interest spending, primarily the cost to service the debt, was $659 billion that fiscal year. A result is that such money cannot be used for more constructive endeavors. Primary deficits are projected to grow over the long term, in large part because of projected increases in spending for Medicare, other federal health care, and Social Security programs compared to relatively lower projected increases in revenue. Proposed solutions are not pleasant and may involve increasing taxes, eliminating popular features of entitlement programs, and changing program eligibility standards, e.g., raising the age for obtaining benefits.
Insurance Consequences Of Biomarker Testing
A fascinating aspect of the health care arena is that there is a steady flow of new technologies and services that have a significant influence on expenditures. Some new medications can result in monthly costs of hundreds of thousands of dollars, which are well beyond the ability of patients to pay for them. Even for drugs that are curative and life saving, how will such costs be financed? A related consideration involves diagnostics. Based on a paper by Arias et al in the February 2024 issue of JAMA Neurology, evidence-based and empirical legal research is needed to develop policy solutions that could mitigate the risk for individuals at risk of discrimination based on biomarker status. Privacy, confidentiality, and anti-discrimination protections are not yet equipped to mitigate potential discrimination risks.
Conscientious Guardian vs. Commercialized Jungle
Apart from the Apple technology product marvels resulting from the work of Steve Wozniak and Steve Jobs in a garage in Redondo Beach, CA, advances in health care have been part of the many changes affecting society. Readers of this newsletter who have grown long in the tooth may recall how common it once was for every neighborhood to have a pharmacy, owned and operated by the individual who served as its founder. The establishment typically bore the name of that person, such as Banville’s Drug Store. When druggist Banville was not in a side room creating a prescription using a mortar and pestle, he might be at the 4-5 stool ice cream section of the store dishing out cones and milk shakes in as many as four different flavors. This individual always could be counted on to assist low income patrons by lancing a boil on a child’s neck at no fee or allowing a grandparent to borrow a cane from the store when that kind of assistance device was needed. Moving ahead to 2024, those establishments have vacated the American scene and been replaced by national chain drug stores that occupy much larger real estate spaces. An article by Richert and Carter in the January 2024 issue of the Journal of the History of Medicine and Allied Sciences focuses on a central debate between pharmacists during the postwar period about how pharmacies were shifting from the role of healer to that of a retailer, from a “conscientious guardian” to a “commercialized jungle,” to highlight how the public health role of pharmacies was undermined by industry pressures for profit.