Until there are big bucks to be harvested from keeping people healthy, don't expect a health-care system like ours to show much interest

I promised recently that we would come back to a crucial point that Paul Krugman made in passing in a recent column on controlling health-care costs: that "preventive medicine [is] an area in which the private sector--which makes money by treating the sick, not by keeping people healthy--has shown little interest."

This is such a complicated subject that I despair of being able to boil down even my primitive understanding of it to the kind of easily digestible news nugget beloved of USA Today and its growing roster of imitators in the print-journalism community, not to mention the short-order cooks of TV "news." In fact, the only reason I "got the message" myself was that on a crucial day I had the patience to digest the whole of a massive New York Times piece on the grim prognosis for controlling Type 2 diabetes, even though the medical community now has an excellent handle on how to do so.

The basic point is this: The way our health-insurance system covers medical costs, it's all but impossible to provide either preventive care or effective management of chronic illness.

I make fun of the NYT a lot, but obviously I also depend on it. What's always frustrating, though, is how far short the paper's coverage falls of its claimed standards of comprehensiveness and comprehension. Yet who else even tries to do the job?

And every now and then the paper thumbs its nose at the horrendous economic pressures against such undertakings and gives its people--many of whom, of course, represent the top talent level in their business--the time and space to do serious reporting, in some breadth and depth, on subjects that matter, or should matter, to all of us. I like to think that these pieces give reporters and editors, and maybe even publishers, a periodic reminder of why they're in the profession they are.

By and large these stories conspicuously lack the pizzazz of "heavy" journalistic fare like the JonBenet murder or the Aruba tourist's disappearance. Oh, I know, I can hear the yawns forming at the mere mention of diabetes, even though the Type 2 form, hand in hand with the obesity epidemic, is reaching crisis proportions in our public health arena. Until I tracked down the article in question, "In the Treatment of Diabetes, Success Often Does Not Pay" (not from the NYT website, by the way, but via the Gadsden Times), I'd forgotten that it was in fact part of a series on the subject.

For what it's worth, though, our interest here isn't diabetes itself. The interest, rather, is that Type 2 diabetes is ravaging the population even though it is to a significant extent preventable, or minimizable, and to an even larger extent manageable with proper care--but that that care, like care for chronic illnesses in general, is almost impossible to provide in our system for purely economic reasons, even though such care would in fact save large amounts of money.

I want to make sure you hear what I'm saying, because I had no idea about it until I read this article. What I'm saying is this: The way our health care system is structured, not only are victims of chronic illnesses basically abandoned, but as a result the total cost is hugely increased.

I hope your response is: "That can't be. It must be some more typical liberal hysteria." Because then at least I know that you've grasped the scope of what I'm claiming. Diabetics and other chronic-illness sufferers are left to suffer the progressive debilitation of their conditions, not because there's no money to treat them, but because we choose to spend vastly more money by waiting until their conditions have deteriorated to the point where our insurance reimbursement system finally kicks in.

Maybe this would be a good point to bring in the opening of this famous NYT article I've been talking about, by Ian Urbina, published this past January (here's the link again):

With much optimism, Beth Israel Medical Center in Manhattan opened its new diabetes center in March 1999. Miss America, Nicole Johnson Baker, herself a diabetic, showed up for promotional pictures, wearing her insulin pump.

In one photo, she posed with a man dressed as a giant foot--a comical if dark reminder of the roughly 2,000 largely avoidable diabetes-related amputations in New York City each year. Doctors, alarmed by the cost and rapid growth of the disease, were getting serious.

At four hospitals across the city, they set up centers that featured a new model of treatment. They would be boot camps for diabetics, who struggle daily to reduce the sugar levels in their blood. The centers would teach them to check those levels, count calories and exercise with discipline, while undergoing prolonged monitoring by teams of specialists.

But seven years later, even as the number of New Yorkers with Type 2 diabetes has nearly doubled, three of the four centers, including Beth Israel's, have closed.

They did not shut down because they had failed their patients. They closed because they had failed to make money. They were victims of the byzantine world of American health care, in which the real profit is made not by controlling chronic diseases like diabetes but by treating their many complications.

Insurers, for example, will often refuse to pay $150 for a diabetic to see a podiatrist, who can help prevent foot ailments associated with the disease. Nearly all of them, though, cover amputations, which typically cost more than $30,000.

Patients have trouble securing a reimbursement for a $75 visit to the nutritionist who counsels them on controlling their diabetes. Insurers do not balk, however, at paying $315 for a single session of dialysis, which treats one of the disease's serious complications.

Not surprising, as the epidemic of Type 2 diabetes has grown, more than 100 dialysis centers have opened in the city.

"It's almost as though the system encourages people to get sick and then people get paid to treat them," said Dr. Matthew E. Fink, a former president of Beth Israel.

I think it was at about this point that I realized I was going to have to read the whole article. To really understand the dimension of unnecessary human suffering as well as economic waste involved, I encourage you to do the same. Let me tack on a few more paragraphs to what I've just quoted:

Ten months after the hospital's center was founded, it had hemorrhaged more than $1.1 million. And the hospital gave its director, Dr. Gerald Bernstein, three and a half months to direct its patients elsewhere.

The center's demise, its founders and other experts say, is evidence of a medical system so focused on acute illnesses that it is struggling to respond to diabetes, a chronic disease that looms as the largest health crisis facing the city.

America's high-tech, pharmaceutical-driven system may excel at treating serious short-term illnesses like coronary blockages, experts say, but it is flailing when it comes to Type 2 diabetes, a condition that builds over time and cannot be solved by surgery or a few weeks of taking pills.

If you want drama, just wait for the scene in which Dr. Bernstein, brimming with confidence from the enormous success of his diabetes program, is summoned to a meeting with Dr. Fink, then still president of Beth Israel, and other hospital administrators--as it turns out, to receive the flabbergasting news that the program is being shut down.

Let me warn you that this is a profoundly depressing piece. Under our present health-care system, there really seems no hope of achieving the almost incalculable savings--in dollars and lives and quality of life--that would be possible through good programs of preventive medicine and chronic-illness management.

Perhaps you're thinking, "But my health insurance company encourages preventive care and 'wellness' programs." Yeah, so does mine, and that's all well and good in its way. Those pamphlets they make available are certainly useful, as long as the information is accurate and up to date. Ditto the discounts on gym memberships and such. Of course, none of this involves significant expenditure--or seriously improves our health profiles.

You're probably thinking that surely health insurers have an economic interest in investing small sums now in order to save themselves much larger payouts later. The grim reality is that they don't. For one thing, most people just don't have a long enough relationship with a particular insurer, so that while the payout of those "small sums now" is real, the future savings, while also real, are too likely to benefit somebody other than that insurer.

It gets worse. As Urbina explains, insurance companies have a powerful dis-incentive. If a company were to cover the cost of a clinic like Beth Israel's which teaches diabetics how to change their lifestyle to prevent or control the onset or progression of the disease, or the test strips that diabetics need to help manage their blood-sugar levels, or those visits to nutritionists or podiatrists, the result would be that the company would be besieged with prospective customers who have or are afraid of developing diabetes. And what insurance companies are looking for is healthy clients, not sick ones.

If you read to the end of the Urbina piece, you risk being left in a state of despair. You will be introduced to a number of people who had their health and hopes raised by the Beth Israel diabetes center, and were then plunged back into a state of medical and economic hopelessness.

Except that, Krugman is suggesting, the kind of medicine practiced in the Veterans Administration health system, by promoting long-term doctor-patient relationships, may actually make inroads in exactly the areas of preventive care and chronic-illness management.

However, standing there in implacable opposition are the right-wing guardians of the "free market."

Some of them, poor souls, actually believe that their mythical free market is the solution to all economic problems. There's something touching about their faith, imbecilic as it is. At least they honestly, if wrongly, believe that somehow problems like those of diabetics will be dealt with by their "system."

Much worse, and unfortunately much more prevalent and powerful today, are the right-wing predators--oops, I mean entrepreneurs, who don't really believe in a free market at all. These are the people who bought themselves a Republican Congress and installed George W. Bush as president. What they want is a system rigged by the government, often with the government as an active participant, to turn every area of our society where dollars change hands into an opportunity for them to vacuum those dollars up.

Under this "system," health care is merely another opportunity to harvest big bucks, just like wars and natural disasters, only much more predictable. After all, we all need medical care.

Could we ask for a better symbol of health care as entrepreneurial pillage and rape than the country's most exalted medical practitioner, Senate Majority Leader Doctor Bill Frist? His family, after all, has been a pioneering force in the new economic frontier of health-care predation.

My advice is not to get sick on Senator Dr. Bill's watch. If you're one of the growing number of people who can't afford health insurance, you're already familiar with this health-care strategy. If you can afford health insurance, while of course you'll be watching your premiums continue to soar, at least as long as you don't actually need medical care the system won't kill you.