Intended for healthcare professionals

Feature Feature

The human cost of overuse

BMJ 2014; 348 doi: (Published 06 May 2014) Cite this as: BMJ 2014;348:g2975
  1. Rosemary Gibson, senior advisor, The Hastings Center, 21 Malcolm Gordon Road, Garrison, New York 10524, USA
  1. gibsonr{at}

Rosemary Gibson looks to the small town of China, Maine, to see the impact that escalating health costs have on a community

State and local governments in the United States are making financial trade-offs as healthcare spending, fueled by overuse, consumes an enormous and growing share of their budgets.

In Massachusetts, state government spending on education and other essential services declined during the past 10 years while healthcare spending jumped 59%, according to Donald Berwick, president emeritus of the Institute for Healthcare Improvement.

Fifteen thousand pairs of used shoes

Similar trends can be found in a suburban New York town where health insurance premiums for the school district jumped 27% in one year. This increase was a factor in the decision to close two schools, including this author’s grammar school. Teachers were laid off. The community held fundraisers to save afterschool music and sports programs. For one of the fundraisers, students collected 15 000 pairs of used shoes, 7 tons of them, to raise $6000 (£3500; €4300).

In an economy with lackluster growth, healthcare employment may increase as spending jumps, but only at the expense of jobs in other sectors such as education—a “robbing Peter to pay Paul” scenario.

The situation in China, Maine

Communities around the country are making trade-offs as healthcare consumes a larger share of their resources. Dan L’Heureux is the full time town manager of China, Maine and understands the trade-offs small towns make.

In the past 10 years, healthcare spending in China increased 152% while the town’s overall budget grew just 41%. According to L’Heureux, when any part of the budget consumes an increasingly greater portion of the community’s resources, there is less money to spend in other critical areas. “Town spending for road maintenance, street lights, police, fire, and recreation has remained flat as healthcare spending has increased,” he said.

China is a scenic rural community with about 4300 residents that is located about 200 miles from the Canadian border and 13 miles from the state’s capital, Augusta. Every year, the town’s citizens elect selectmen and outline the budget for the coming year. The selectmen appoint a town manager to oversee daily operations. In a place where the average snowfall is six feet, one of the town manager’s roles is to ensure the roads are plowed and safe for residents to travel.

L’Heureux also understands healthcare in his role as chair of the board of Maine Quality Counts, a state-wide organization comprised of hospitals, physicians, public health and aging organizations, patients, and family members. Its aim is to ensure all residents have safe, timely, effective, efficient, equitable, patient centered, and coordinated care, while being mindful that resources are not unlimited.

China spends about $200 000 a year for health insurance for its 11 employees, or an average of $18 000 a year per person. Healthcare premiums are considered part of the employees’ benefit package. As the cost of healthcare premiums for employees rises, they have less money in their paychecks to spend for themselves and their families in local businesses, places of worship, and other activities.

“Communities make trade-offs every day,” L’Heureux said. “Often, they are invisible but they are real and affect the quality of life in our towns.”

The invisible trade-offs of increased healthcare spending

Emblematic of the trade-offs, China has three volunteer fire departments. They purchased updated equipment with funds from federal Homeland Security grants. In 2013, one of the departments purchased a newer fire truck built in 1985 as a way to stretch limited resources. While better than the fire truck the town had been using, it is 30 years old.

Trade-offs can affect the safety of the volunteer firefighters. They needed new safety equipment that helps them when they attack a structural fire in a building. With their 20 year old equipment, firefighters had to read a gauge on the oxygen bottle to find out if they had enough oxygen, which can be very difficult in a burning, smoke filled building. Newer facemasks are equipped with a digital readout of how much oxygen remains, which is much safer for the firefighters. The town purchased the new equipment because it received grant funding.

Road maintenance is the largest budget item in China. The town has a long term road improvement and resurfacing plan to keep roads from deteriorating. To stay within budget for road maintenance, the town uses temporary fixes such as sealing emulsion to fill in cracks in the road surface and prevent water from seeping in. If essential maintenance is postponed for too long, costs skyrocket as roads have to be reconstructed rather than resurfaced.

A homespun analogy might be placing masking tape on small cracks in the foundation of a house when there isn’t money to repair them. As water continues to seep in, the cracks become larger and more costly to repair.

Safety is a priority for China’s town manager. About 85% of the community’s employed residents work outside the town and drive day and night. Roads need to be in good condition to ensure their safety. Traffic loads, combined with snow and ice conditions in winter, cause the roads to deteriorate more rapidly than in warmer climates.

Trade-offs are made in other parts of the town budget. “The operating budget for the police department, which employs one part time officer who receives a stipend and no health insurance benefits, is about the same as the cost of health insurance for one employee,” L’Heureux said. One of the reasons for not having a full time officer is that resources are allocated elsewhere.

The same is true for the rescue department and each of the town’s three volunteer fire departments, an inevitable outcome when one part of the budget consumes an increasingly larger portion of the total.

Overtreatment and overspending

China is not the only community facing this dilemma. It is one of 2000 municipalities in the US with fewer than 5000 people (400 of them are in Maine). L’Heureux believes they are making trade-offs, too.

Maine Quality Counts is launching conversations throughout the state about overtreatment as part of the Choosing Wisely campaign. Sponsored by the American Board of Internal Medicine Foundation, Choosing Wisely engaged national medical specialty societies to identify the top five tests and procedures in their specialty that should be done less frequently. Consumer Reports is translating this information for the public. The aim is to encourage physicians and patients to have conversations about tests and procedures that are overused.

In the meantime, as healthcare consumes a larger share of their resources, states and communities across the country continue to make the trade-offs that often remain invisible to residents.


Cite this as: BMJ 2014;348:g2975


  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned, not externally peer reviewed.

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