Health care isn't getting more expensive because of all those aging boomers, or because doctors are ordering too many tests.
The bigger problem these days is how much we're being charged for drugs, hospital stays, doctors and bureaucracy, according to an analysis in JAMA, the American Medical Association's journal.
Those items have accounted for almost 91 percent the increase in health care spending since 2000, the researchers say.
"That was surprising," Dr. Hamilton Moses, the lead author of the study and an adjunct professor at Johns Hopkins University School of Medicine, said Tuesday at a media briefing in Washington, D.C.
The politicization of the debate over health care has perpetuated myths about health care spending and has made it harder for people to get a grip on what's happening with a vast and splintered industry, Moses said. That prompted him and his coauthors to try to take a panoramic snapshot.
It's not a pretty picture, by and large.
Health care costs have tripled in real terms in the past 20 years, the study found by analyzing public data, and now account for about 18 percent of the country's gross domestic product, or $2.7 trillion.
But by most indicators Americans aren't getting a good return on that investment. Increases in life expectancy are slowing in the United States compared to other developed countries, the study found. Those results are consistent with other researchers finding. We're doing a worse job treating many major ailments, including cardiovascular and infectious disease. Cancer is the only major disease where the U.S. did better.
How Americans get sick has changed a lot since 1980, and that's reflected in these numbers, too. Gone are the days when people only showed up at the hospital when they had a heart attack. In 2011, chronic illnesses like diabetes and cancer accounted for 84 percent of the nation's health care costs, the report says.
But that's not because of aging baby boomers. Instead, people younger than 65 with chronic illnesses accounted for almost three-quarters of health care costs.
Since 1980, the federal government has paid a larger share for health care, and individuals have paid less. The federal share rose from 31 percent in 1980 to 42 percent, the report says. Personal out-of-pocket spending for insurance premiums and copays dropped from 23 percent to 11 percent.
The picture's not entirely grim, Moses says. The fact that the industry is consolidating, with doctors working for hospitals or large groups rather than in solo practices, may make it easier to make health care more efficient, safe and consistent.
But the dawn of "Big Med," as the authors call it, also means that medical care may become less personal. Say farewell to the family doctor; say hello to doc-in-the-box clinics.
In many ways, Big Med may end up looking like the airlines do now, Moses told Shots. "You can fly from New York to Los Angeles at the lowest possible cost. Safety will be higher, yet the consumer experience is abysmal."
If you're not comforted by this, you're not alone. Moses says that patients have been largely left out of the political debate in Washington and efforts to reshape the system.
So how do patients get their say?
"I don't have an easy answer to that question," Moses says. As prices for treatments become available, patients should have more choices, but they'll need to make their expectations known. "At a very, very individual level that can be effective," he added.
Indeed, the most optimistic report in this JAMA special issue, which featured many of the big guns in health policy and research, comes from Dr. Joshua Sharfstein, who runs Maryland's health department.
In an editorial, Sharfstein points to coordinated care organizations in Oregon, health care cost targets in Massachusetts, and global budgets for hospital care in his own state. He calls them "railroad tracks" for a new health care system that would still give local doctors and patients some control.
At the briefing, Sharfstein spoke of how much he would like to be able to spend health care money on a handyman to tack down the carpet in an old lady's apartment, rather than wait until she falls and ends up in the hospital with a broken hip.
"This may be too much for Washington right now," Sharfstein said.