Health at all costs?

On better defining the priorities of our investment in health.

Public health is fundamentally a story. My new book, Within Reason: A Liberal Public Health for an Illiberal Time, is about how we can ensure that story is guided by our values. Here is a reading from the chapter “Liberty and Health“. Thank you for supporting the ideas in The Healthiest Goldfish, and those in the book. Within Reason will be available December 1, and can be pre-ordered here.

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How do we determine value? Does everything have a price? Perhaps most relevant to readers of this newsletter: what is the value of health? It may seem odd to even raise this question. Yet the truth is that we do put a price on health all the time. The average annual cost of insulin for an individual (about $6,000), the annual cost of HIV antiretroviral therapy (average price over $36,000), and the cost of a kidney transplant (average price about $442,500). There is a whole field of study, largely under the umbrella of decision science, that works to quantify everything from the price of different health interventions to a human life itself. Such work helps inform decision-making in a range of sectors, including business, law, public health, and regulatory work at the federal level. Throughout the history of government regulation, federal agencies have tried to put a dollar value on a single life for the purposes of weighing the tradeoffs involved in adopting new regulations. Core to such tradeoffs is being able to weigh the cost of a given approach, within a finite resource pool, which then necessitates placing a dollar value on a life. According to various calculations made at various times and by various agencies since the 1970s, a single life has been valued at $885,000, $1 million, $2.5 million, $7.4 million, $8.7 million, and $9.6 million.

These calculations reflect how we do indeed put a price on health. There is a paradox at the heart of this that is worth acknowledging, in which the price we put on health is often far too high and at the same time not high enough. It is too high in that expensive treatments can put quality healthcare out of reach for many. It is not high enough because most people would likely agree that even the most astronomical sum falls short of the true worth of a human life. 

What does our effort to grapple with value in the context of health mean for our pursuit of health at the population level? My interest in how we value health, and the costs we are willing to incur to support it, comes principally from three observations. First is the tried-and-true aphorism, perhaps the fundamental truth for all who are ahead of us in life’s journey, that all that matters is good health. This suggests that health may indeed be priceless, setting up an ideal which runs into challenges when it meets the cost-benefit analysis that inevitably characterizes our real-world engagement with health. Health may be priceless, but resources are finite, so we cannot avoid thinking about costs in a context of health.

This leads to the second observation, that casual conversation often leans on the notion that we should prioritize health at all costs. Most of us are understandably uncomfortable thinking about what may happen when our health needs outpace our capacity to pay for them. Likewise, many, if not most, of us in public health recognize that we cannot indefinitely do what it takes to place health above every other consideration. Yet, during the pandemic, we often strayed from this understanding, pursuing polices which, in effect, amounted to a health-at-all-costs approach, with health narrowly defined as the absence of disease rather than as the ability to do all that supports a happy, fulfilled life. Third, and somewhat amusingly, there seems to be growing interest among the very wealthy in spending vast sums on research and therapeutics that aim to slow, even reverse, the aging process. Some proponents of this even go so far as to claim death itself is merely a medical problem to be solved and that it may yield to disruptive Silicon Valley-style innovation.

Each of these observations is informed by the suggestion that we should pursue health at all costs and that no price is too high for doing so. What is more, we often hear the suggestion that, if we do not do so—if we act instead according to a more pragmatic cost-benefit calculation—we are in some way morally deficient. This criticism is not difficult to understand. We get into public health because we keenly feel the inadequacies of the status quo around many issues that matter for health. From this perspective, it is not hard to see why seeming to put a price on health can appear to contradict our goal of creating a healthier world for all. After all, who is going to argue (except perhaps decision scientists) that our life has a price, with the implication that preserving it at all costs might be less urgent than other priorities? Yet the aim of this essay series is to ask the questions that we typically do not ask. In this series of reflections on this post-war, post-COVID context, now is a time for engaging with questions like: does health indeed have a price? If so, who sets it? What does this mean for thinking about health? And should we really pursue health at any cost, including at the expense of living the kind of life health enables?

Before we can answer these questions, we must return, once again, to what we mean by “health.” What we mean by health determines what we are willing to do for health, whether we are willing to advance health at all costs. In this newsletter, I have often argued that “health” should be a means to an end, and that end is the ability to live a rich, full life in a context of dignity and opportunity for everyone. This means that we should take no action in pursuit of health that undermines what health is fundamentally for. We should be willing to spend much on whatever supports the living of a fully realized healthy life. This includes spending on everything from wheelchair ramps and accessible reading materials for students to things like safe exercise opportunities in all neighborhoods so that kids who are gifted at sports are discovered early and can achieve their full potential. It may seem that such spending is incidental to health, and that “real” health spending is our investment in the drugs and treatments that help extend life. But what is life if it is without what makes it most meaningful? Education, the opportunity to discover and develop talents, the chance to enjoy nature, having the time to build and maintain connections with family and friends—this is the stuff of a healthy life, and nothing is more worthy of investment. If we are willing to spend vast sums on defense, on keeping afloat corporations which are “too big to fail,” and on other national priorities, we should be willing to spend just as much on the social and material resources that support a healthy life. This means shaping a public conversation where health is understood as more than simply the treating of disease and the prolonging of life. Health is the full range of social networks, material goods, and human experiences that make life meaningful and worth living.

So, the argument is not about whether we are willing to achieve health at all costs, but whether we are willing to build a society that allows us all to live a life with dignity, that maximizes opportunity at all costs, that supports time with friends, colleagues, and loved ones. What does it mean to embrace such a vision? What would it cost?

Principally, it means that investment in health becomes largely a matter of social ventures, which is a question of priorities. It is in some ways simpler to invest in health by way of healthcare alone. Doing so means mostly confining investment to a single sector—healthcare. When we invest in health, rather than just healthcare, we are faced with a more complex task. We then must evaluate the costs and benefits across a range of sectors, from education, to urban development, to agriculture, to shoring up the social safety net. This process of evaluation means we must indeed weigh the costs of certain interventions against others, always looking to maximize our investment. But this does not mean we should accept an ever-greater expenditure on healthcare at the expense of the forces that shape health. We currently spend about $4 trillion annually to optimize what we call health, but this investment largely goes to healthcare.  How much healthier would our world be if we spent that much on the social and physical environment that allows us to live richly realized lives? What if we invested trillions each year in measures like tackling economic inequality, addressing systemic racism, building healthier urban spaces, and subsidizing nutritious foods? A world supported by such investment would be worth paying a high price for indeed.

Such an approach to our investment in health provides, I think, a unifying conceptual framing for our actions. It means, for example, that during a pandemic we should be protecting health, but not at the expense of maximizing the dignity-opportunity space. We should invest in treatments, yes, and take reasonable precautions against getting sick. But as soon as the data support it, we should pursue an approach that balances treatment and protecting the most vulnerable with allowing as many people as possible to live as fully as possible.

Most of those who work in the health space would likely agree with what I have been saying in this newsletter about supporting health to the end of supporting a good, full life. The notion that we need to invest beyond healthcare in the foundational determinants of health, forces which align with the living of a full life, are core to public health thinking. But, in practice, we can find ourselves slipping into arguments which have more than a little in common with the billionaires looking to reverse aging and cure death. Most of us would likely laugh at the idea of spending absurd amounts of money trying to #disruptdeath, yet is the idea really so different from trying to eliminate all risk of disease within populations without regard for the costs or tradeoffs involved?

In our zeal to safeguard health, we can sometimes lose sight of what health is for, why it is a good worth promoting in the first place. This reflects why it is important to continue to have conversations about the first principles of our field, the philosophical underpinnings of why we do what we do. Core to this is consideration of the costs we are willing to incur for health. If we want to discuss the cost of health, we must also discuss what we mean by “health,” and the kind of world our vision for health entails. If our vision for health is limited to the elimination of risk and the extension of life, we should continue to talk about health in terms of better treatments and technology and spare no expense in their pursuit. If, however, we want a better world that allows everyone to live with dignity, opportunity, and access to the full range of social and material goods that support a healthy life, we should have a different conversation indeed. 

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Also this week.

Thank you Jim Shultz and Lisa Sullivan for leading us on the publication of the second edition of our introductory public health textbook, Public Health: An introduction to the science and practice of population health. Thank you to the teachers and students who have adopted the first edition over the past few years, helping us improve the second edition. The book is here.

A piece in Frontiers in Public Health about the importance of a diversity of ideas in academic spaces.