Nothing is so common these days, and actually for many years now, than talk of the need for health care reform. There is hardly a country in the world where one can not find such a discussion, and often heated debate, about the future of its health care system.
One might indeed see the need for a reform as a kind of chronic disease of modern medicine and health care systems. Moreover, once some reforms are put in place, one can be sure that there will soon be a call for still another round of reform. Almost always the need for reform centers on the cost of health care, and how to manage and control those costs. And nothing seems to work for very long.
What is the cause of this chronic disease? Part of it is surely political, a function of changing parties and ideologies with different agendas to put in place. But a more fundamental reason is the nature of modern medicine, and a medicine that must cope with a changing demographic scene. There are three major reasons for the constant stress.
One of them is the fact of aging societies, a reality true of all western developed countries. There are a growing number and proportion of elderly, with even greater numbers and proportions expected over the next few decades. Since it is commonly estimated that health care of those over 65 is approximately four times as much per capita as those under 65, further financial difficulties can be expected.
Another reason is the constant introduction of new, and usually more expensive, technologies--notably new drugs and devices--and the intensified use of older technologies. And still another reason is the increased public demand for good, and for that matter even better, health care. Modern people have come to expect constant improvement in medicine and health care. What was adequate care a decade ago is rarely considered adequate any longer; and this year’s level of care is not likely to seem adequate a decade in the future.

Medical Progress and Technological Innovation
Of all these reasons, however, I believe that medical progress and technological innovation are the most important. In the United States the estimate is that from 40% to 50% of cost increases can be traced to the technological factor, and I suspect something similar may be true in Europe. The net result of the technologies and other factors in the United States has been an average general system-wide cost increase of 10%-15% a year for the past several years, and with no end in sight. European countries I know are under severe costs pressures as well, even if perhaps not so much as in the United States.
What is to be done about this problem? It will simply not be possible for health care systems in developed countries to continue down this path. The major threat of escalating costs is to undermine the ideal of equitable access to health care, which most European countries have realized over the decades. A lesser threat, but not trivial, is that of constant legislative struggles about health care, rationing of an open and covert kind, and increasing public dissatisfaction with health care.
Many efforts at reform are underway, and I will simply mention some of the most prominent: increasing use of co-payments and deductibles, privatization of parts of health care systems, long waiting lists for elective surgery and other forms of non-emergency care, the use of evidence-based medicine to better determine which treatments are efficacious, and various forms of rationing.
All of those efforts are important, but I want to suggest that they are not likely to work much better in the future than in the past—and that, if we limit ourselves to them, the reform crisis will continue, and even get much worse. I call all of those methods administrative and organizational; that is, an effort to change the system in some clever way to deal with the cost problem.
But, given the nature of the problem, there is no way we can be that clever. We must think about the problem in a much deeper, even more radical way. We need to change our ideals and some of our modern values about medicine and health care—and not simply try to find better ways to reorganize existing systems, important as that is.

A Sustainable Medicine
We need what I call a “sustainable medicine,” and the key to such a medicine requires a rethinking of the idea of medical progress and constant technological innovation. By a “sustainable medicine” I mean an idea, or even vision, of medicine and health care that aims to be (a) equitable and accessible to all, (b) affordable to national health care systems, and (c) equitable and affordable in the long run, not simply for a few years. I take the notion of “sustainability” from the environmental movement, one of whose aims is to have an earth that can sustain human life of a good quality for the indefinite human future, one that knows how to avoid ruining the atmosphere and the earth in ways that would harm future life. I am looking for an analogous idea in health care.
We do not have at present sustainable health care systems in any country. Constant medical progress, adding to costs, and aging populations, also adding to cost, guarantees they will be unsustainable—and thus guaranteeing a threat to universal health care and an affordable medicine. If medicine is unaffordable, it can not be equitably distributed; only the wealthy will be able to get it.
I have already indicated why I do not believe that organizational and managerial reform can cope with the present unsustainable situation. Nothing less than some fundamental rethinking is needed. If there is to be a sustainable medicine we will need to formulate in some fresh way the idea of progress that drives the technology costs and feeds public demand and, along with that, come to accept the idea that sooner or later we will have to reach some plateau of both progress and thus health care spending.