As goes college, so goes health care?

My oldest child is applying to college this year. He is an outstanding student and likely to be offered significant scholarships, so my wife and I are not concerned about him (and us) being able to afford the tuition to the college he ultimately chooses. Tuition and fees at U.S. colleges actually increased at a lower rate than general inflation from 2022-23, breaking a 20-year trend that saw tuition increases for private and out-of-state public schools far outpace concurrent rises in incomes and costs of living. As a result, college has become less and less affordable, particularly for students who end up relying mostly on loans and rack up gigantic debt loads even if they don't complete their degrees.

But college-educated adults earn a lot more money than those without college diplomas, so going to college still makes economic sense, right? Maybe not. A few months ago, a New York Times Magazine story by Paul Tough (whom I've quoted previously on my blog) discussed "the new economics of higher ed." He cited the work of three researchers at the Federal Reserve Bank of St. Louis who found that looking at wealth accumulation rather than income, college graduates born in the 1980s or later had little advantage over their peers who didn't gradate from (or even start) college, with Black and Latino college graduates worse off than White college graduates. Data on postgraduate degrees was even more bleak: there seemed to be no wealth advantage at all.

Millennials with college degrees are earning a good bit more than those without, but they aren’t accumulating any more wealth. How can that be? ... The likely culprit, [one researcher] said, was cost: the rising expense of college and the student debt that often goes along with it. Carrying debt obviously diminishes your net worth through simple subtraction, but it can also prevent you from taking important wealth-generating steps as a young adult, like buying a house or starting a small business. And even if you (or your parents) were able to pay your tuition without loans, the savings you used are gone when you graduate, and thus are no longer available to serve as a down payment on a starter home or the beginning of a nest egg for retirement.

Fueled by skyrocketing tuition costs, total student loan debt more than tripled from $500 billion in 2007 to $1.6 billion today, and in an even more stunning statistic, "among student borrowers who opened their loans between 2010 and 2019, more than half now owe more than what they originally borrowed."

It's possible that demographic trends will act to moderate tuition costs in the future; as the pool of students finishing high school shrinks, colleges may need to keep tuition increases low to compete financially. For the sake of my pocketbook (my high school senior son is the oldest of four children), I certainly hope so. But reading about higher education made me think about another sector where costs and fees have been rising exponentially while the return on investment is middling and the quality of the product remains opaque: health care.

Since 1980, the U.S. has spent more on health care as a percentage of its gross domestic product than any other country in the world; today, nearly 1 in 5 dollars generated by the American economy goes to the purchase of health care. Yet average life expectancy stopped rising in 2010 and plummeted during the first two years of the COVID-19 pandemic, far more than in comparable countries where the average resident lives 5-6 years longer than we do. Further, U.S. men now are expected to die 6 years earlier than women, the widest gender gap in nearly 30 years, according to a recent study in JAMA Internal Medicine. The biggest drivers of this gap were deaths from COVID-19 and drug overdoses, which medicine can prevent with highly effective interventions: vaccines, medications to treat opioid use disorder, and the opioid reversal agent naloxone.

It's not that patients aren't enthusiastic about prevention. We spend $35 billion per year on largely worthless over-the-counter dietary supplements. According to a recent analysis of data from the National Ambulatory Medicare Care Survey, the proportion of primary care visits "with a preventive focus" increased from 12.8% in 2001 to 24.6% in 2019. But the services doctors provide at those "wellness" visits - mammograms, PSA tests, colorectal cancer tests, and CT scans for lung cancer - generally don't help people live longer and often lead to unintended harms. While discrete medical services don't save lives, we know that having a relationship with a primary care physician does. Good luck getting in to see one, though, when the pay gap between primary care and subspecialists discourages medical students from becoming family physicians, and the percentage of health care dollars invested in primary care nosedived from 2013 to 2020.

Will the U.S. eventually reach a "breaking point" when, like college today, people realize that they are being fleeced by a self-perpetuating sick care system and demand greater value for their money? Such as sending more of the trillions of dollars spent on health care toward primary care? Some states are starting to recognize the wisdom of increasing primary care spending, but progress has been slow. Our country would do well to heed this advice that I've adapted from food writer Michael Pollan: Get real health care. Not too much. Mostly primary care.