Social Science & Medicine 70 (2010) 1943e1947

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Social Science & Medicine

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Short report

Estimating the costs of medicalization

Peter Conrad a, *, Thomas Mackie a, Ateev Mehrotra b
a
b

Department of Sociology, MS-71, Brandeis University, Waltham, MA 02454, United States

Rand Corporation, Pittsburgh, PA, United States

a r t i c l e i n f o

a b s t r a c t

Article history:
Available online 10 March 2010

Medicalization is the process by which non-medical problems become dened and treated as medical
problems, usually as illnesses or disorders. There has been growing concern with the possibility that
medicalization is driving increased health care costs. In this paper we estimate the medical spending in
the U.S. of identied medicalized conditions at approximately $77 billion in 2005, 3.9% of total domestic
expenditures on health care. This estimate is based on the direct costs associated with twelve medicalized conditions. Although due to data limitations this estimate does not include all medicalized
conditions, it can inform future debates about health care spending and medicalization.
2010 Elsevier Ltd. All rights reserved.

Keywords:
Medicalization
Cost of health care
Health spending
USA

Introduction
The percent of the U.S. gross domestic product spent on health
care has risen from 4.5% in 1950 to 16% in 2006 (Congressional
Budget Ofce, 2008). Numerous explanations have been offered
for this increase including the development and use of medical
technology (Rettig, 1994), the aging population (Reinhardt, 2003),
and particular reimbursement mechanisms (Bodenheimer, 2005).
Critics have suggested medicalization as another potential explanation for increasing health care costs (Budetti, 2008; Hadler, 2008;
Szasz, 2007), but to our knowledge no previous studies have
systematically tried to estimate the costs of medicalization. In this
paper we dene medicalization, present a strategy for estimating
the cost burden of medicalized conditions, and estimate 2005 US
spending on medicalized conditions.
For more than three decades numerous scholars have described
the process of medicalization and how an increasing number of
conditions has come under medical jurisdiction (Conrad &
Schneider, 1992; Zola, 1972). Medicalization is a process by which
non-medical problems become dened and treated as medical
problems, usually in terms of illnesses or disorders. Examples
include menopause, alcoholism, attention decit hyperactivity
disorder (ADHD), post traumatic stress disorder (PTSD), anorexia,
infertility, obesity, sleep disorders, erectile dysfunction (ED), among
others (14). The growing interest in medicalization is seen in the
number of symposiums about medicalization in places such as the
British Medical Journal (Special Issue on Medicalization, 2007), the
Presidents Council of Bioethics (Kass, 2003), PLoS (Moynihan &

* Corresponding author.
E-mail address: conrad@brandeis.edu (P. Conrad).
0277-9536/$ e see front matter 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2010.02.019

Henry, 2006), and Lancet (Metzl & Herzig, 2007). In both the
social science and medical literature, the major focus has been on
documenting the rise in medicalization, debating conditions which
constitute medicalization, and identifying the implications for
patients, medicine and society.
An underlying theme in this literature is the concern about
overmedicalization. While medicalization describes a social
process, like globalization or secularization, it does not imply that
a change is good or bad. Some observers have raised the concerns
that medicalization is an over-expansion of medicines professional
jurisdiction and is a mechanism by which the pharmaceutical
industry can increase markets, thus contributing to rising health
care costs (Moynihan & Cassels, 2005). While these issues have
been raised repeatedly, to our knowledge, no analysis of medicalization has attempted to estimate the scal impact on health care
spending. Recognizing that there are many difculties in such
a task, not the least of which is dening what conditions are forms
of medicalization, we believe such an estimate would be an
important addition to the literature. While it is clear that in the last
three decades there has been a signicant growth in the number of
medicalized conditions as well as number of patients treated for
those conditions (Conrad, 2007), we seek to address what contribution this trend has had on the societal problem of spiraling health
care costs.

Methods
Identifying medicalized conditions
A key issue in this study was to identify medicalized conditions.
Selection of medicalized conditions was based on two criteria: 1)

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P. Conrad et al. / Social Science & Medicine 70 (2010) 1943e1947

a published study identied the condition as an example of medicalization since 1950 (Ballard & Elston, 2005; Barsky & Boros, 1995;
Conrad, 1992, 2007) and 2) the availability of reasonably valid and
current data on US national medical expenditures for that condition. In the end, we included 12 conditions (see Table 1). Schizophrenia and bipolar illness (manic depressive disorder) were
deemed a medical problem before 1950 (even as bipolar illness has
become a more common diagnosis in recent years). We were
unable to nd reliable national estimates for medicalized conditions such as eating disorders, idiopathic short stature, chronic
fatigue syndrome, and bromyalgia (Conrad, 2007). Due to the
limited availability of data, we only included costs of pharmaceutical drugs for erectile dysfunction and male pattern baldness, and
for obesity we only estimated the costs of bariatric surgery and
weight loss medication, excluding medical visits.
We recognize that medicalization is dimensional and on
a continuum; there are degrees of medicalization from conditions
that are thought to be minimally medicalized (e.g. sexual addiction
or multiple chemical sensitivity disorder) to almost completely
medicalized (e.g. childbirth or major depression). Once established,
medicalized categories can be exible, expanding or contracting.
For example, post traumatic stress disorder (PTSD) emerged in the
1970s as an ailment among Viet Nam veterans (Young, 1995) but
now PTSD includes survivors of all kinds of trauma (e.g., physical,
sexual, environmental, etc.) and even witnesses to traumatic
events. Medicalization has variable involvement from the medical
profession. For example, alcoholism treatment involves relatively
few physicians, while physicians play a central role in surgeries
such as gastric bypass for obesity. Finally, medicalization is bidirectional. While the trend has been overwhelmingly toward
increased medical categories and interventions in the past four
decades, there are a few examples of demedicalization, such as the
demedicalization of homosexuality since the 1973 APA decision
(Bayer, 1985). Thus the selected conditions were, at the time of data

Table 1
Medicalized conditions.
Medical condition

Dened by diagnosis of the following condition or use

of the indicated health services or pharmaceutical

Anxiety disorders

Social phobia, anxiety states, dissociative, conversion

and factitious disorders, obsessive compulsive disorder,
neurasthenia, depersonalization disorder.
Behavioral disorders
Attention decit disorder without and with mention of
hyperactivity, conduct disorder, and oppositional
deant disorder.
Body image
Cosmetic procedures and surgeries (does not include
bariatric surgery.)
Erectile dysfunction
Pharmaceutical use of Viagra, Cialis, Levitra.
Infertility
Includes primary and secondary female infertility and
primary male infertility.
Male pattern baldness Pharmaceutical use of Propecia, Rogaine, and Minoxidil.
Menopause
Pharmaceutical use of Premarin family.
Normal pregnancy
In-patient deliveries, excludes all non in-patient
and/or delivery
deliveries and those with complications (e.g.,
hypertensions or diabetes complicating childbirth,
early labor or prolonged delivery, and malpositioned,
obstructed, or foreign deliveries). Caesarean sections
are included in this analysis unless they had been coded
as a complication of birth.
Normal sadness
Expansion of depression to include normal sadness
between 1990 and 2000.
Obesity
Bariatric surgery and weight loss medications.
Sleep disorders
Treatment for insomnia.
Substance related
Treatment for alcohol, amphetamine, cannabis, cocaine,
disorders
inhalant, nicotine, opioid, phencyclidine, and sedative
dependence.
Table 1 lists the 12 medicalized conditions included in this study. The table also
species the way in which each condition is dened for the purposes of this study.

collection, predominantly under medical jurisdiction being both

dened and treated medically.
Estimating the cost of the twelve conditions
Cost-of-illness studies use a systematic method to identify and
to calculate direct and indirect costs of treating and managing
a particular condition or illness (Rice, 1994). In this study, our focus
is specically on how medicalized diagnostic categories increase
national health care expenditures. Medical direct costs are dened
as payments to hospitals, pharmacies, physicians, and other health
care providers. These costs may be paid by the individual and their
family, private and public insurance, or other payment sources. We
therefore exclude non-medical direct and indirect costs such as
transportation costs and decreased productivity or missed work.
This study uses multiple data sources that were ranked
according to the empirical strength of each data source. Our use of
multiple data sources is similar to how the federal government
estimates national health expenditures yearly (Mehrotra, Dudley, &
Luft, 2003). Our primary source was 2005 data from the Medical
Expenditure Panel Survey (MEPS), released by the Agency for
Healthcare Research and Quality AHRQ, 2008. MEPS is a nationally
representative dataset of the non-institutionalized population in
the United States (Cohen, 1997). The dataset has been widely used
to estimate the medical expenditure related to different types of
conditions or types of care (Chan, Zhan, & Homer, 2002; Sturm,
2002; Trogdon & Hylands, 2008). For each household in their
panel, MEPS regularly collects detailed information for each person
in the household on the following: demographic characteristics,
health conditions, health status, use of medical services, charges
and source of payments, access to care, satisfaction with care,
health insurance coverage, income, and employment. MEPS then
goes to each of the individuals identied providers and collects
data on dates of visits/services, use of medical care services, charges
and sources of payments and amounts, and diagnoses and procedure codes for medical visits/encounters (AHRQ, 2008).
Priority was given to these data for multiple reasons. First, the
database allows for primary analyses of national expenditures for
many of the identied medicalized conditions. The use of these data
as our primary data set aimed to strengthen this study by reducing
variation in the design and estimation techniques. Second, MEPS
uses person level weights to generate a nationally representative
sample and to correct for selection bias. Finally, numerous other
studies have used the MEPS data to document the cost of health
conditions ranging from pregnancy to pediatric behavioral health
care (Guevara, Mandell, Rostain, Zhao, & Hadley, 2003; Machlin &
Rohde, 2007). While data from MEPS were used when available,
estimates were next selected from peer-reviewed publications,
technical reports, annual sales reports from pharmaceutical companies, and lastly newspaper articles. The reliability of technical reports,
annual sales reports, and newspapers are limited as these data points
have not undergone scholarly review. We recognize that these data
have limitations, but felt they were necessary for an initial estimation
for the cost of medicalization that will require further renement.
Table 2 provides a list of the data sources used in this study, specifying
the type of data source, type of health service utilization, medical
conditions, and the payers of these services, when available.
This study implements three estimation techniques to ascertain
the impact of medicalization on national health care spending.
First, medicalized diagnostic conditions are used to identify relevant costs for medical care and treatment. This estimation technique is the strongest, by assuring that all medical expenditures are
linked to the medicalized condition. As described in Table 2, this
strategy is used for uncomplicated pregnancy, anxiety disorder,
substance related disorder, behavioral disorders, and infertility.

P. Conrad et al. / Social Science & Medicine 70 (2010) 1943e1947

1945

Table 2
Description of data sources and estimation techniques.
Data source (citation)

Type of data Type of health

source
service utilization

Medical
conditions

Medical expenditure panel survey

(AHRQ, 2008)

Primary data * In-patient visits

* Out-patient
analysis &
peerofce visits
* Emergency
reviewed
journal
department
visits
* Pharmaceutical
drugs

* Uncomplicated * Private and

public sector
pregnancy
* Out-of-pocket
* Anxiety
expenditures
disorder
* Substance
related
disorder
* Behavioral
disorders
* Female
infertility
* Male infertilitya
* Normal sadness * Private and
public sector
* Out-of-pocket
expenditures

* In-patient visits
* Out-patient
ofce visits
* Emergency
department
visits
* Pharmaceutical
drugs
* In-patient visits
National ambulatory and medical
Peer* Out-patient
care survey (Walsh & Engelhardt, 1999)
reviewed
journal
ofce visits
* Emergency
department
visits
* Long-term care
* Pharmaceutical
drugs
Pharmaceutical companies (Berenson, 2007; Annual sales * Pharmaceutical
Eli Lilly & Company, 2006; Glaxo Smith
report
use, including
Kline, 2005; Pzer, 2005; Wyeth, 2007, p. 2)
Viagrac, Levitra,
& Cialis
* Pharmaceutical
use, including
Premarin family
* Pharmaceutical
Medical bulletin (Anonymous, 1998)
Technical
report
use, including
Propecia,
Rogaine, &
Minoxidil
National comorbidity study
(Greenberg et al., 2003)

Healthcare Utilization and Cost Project and

Medstat 2002 market-scan commercial
claims and encounter database (Encinosa,
Bernard, Steiner, & Chen, 2005)

Peerreviewed
journal

Peerreviewed
journal

American society for aesthetic plastic surgery Technical

survey (ASAPS) (American Society for
report
Aesthetic Plastic Surgery, 2008)

Payer

Estimation techniques
For primary analysis of MEPS data, conducted
a weighted analysis for each medicalized
condition to reect complex sampling design of
the survey. Used Statistical Analysis Software
(SAS), Version 9.1.3TM.

Acquired estimate for annual medical

expenditure on sadness at 1990 and 2000 from
Greenberg et al., 2003. Adjusted both the 1990
and 2000 to 2005 dollars, and then subtracted to
arrive at an estimate for normal sadnessb.

* Insomnia

* Private and
public sector
* Out-of-pocket
expenditures

Acquired estimates for direct medical costs for

insomnia from Walsh and Engelhardt study, and
then adjusted the 1994 to 2005 US dollars.
Estimate of male infertility, arrived from National
Ambulatory Care Society, adjusted estimation to
2005 dollars from 2000 dollars.

* Erectile
dysfunction
* Menopause

* Not available
(pharmaceutical sales)

Acquired annual sales reports for US sales of

Levitra, Cialis, and the Premarin Family. Viagra
estimate arrived from a 2007 New York Times
article, which reported annual sales in 2006 US
dollars. The estimate in 2006 US dollars was
adjusted to 2005 US dollars.

* Male pattern
baldness

* Not available
(pharmaceutical sales)

Acquired estimate from the Medical Bulletin,

which acquired estimates from the annual sales
reports of the respective distributors for US sales
of Propecia, Rogaine, and Minoxidil. All estimates
were adjusted from 1998 US dollars to 2005 US
dollars.
* Obesity,
* Obesity (Bari- * Private and
Acquired estimate for direct medical costs
including bariatric surgery
public sector associated with bariatric surgery and prescription
atric surgery and and weight loss * Out-of-pocket weight-loss medication from study by Encinosa
weight loss
medication)
expenditures et al. Estimates were adjusted from 2002 US
medication
dollars to 2005 US dollars.
* Body image,
* Body image
* Private and
Acquired 2005 estimate for invasive and nonincluding
(cosmetic
public sector invasive cosmetic surgeries and procedures.
cosmetic proceprocedures and * Out-of-pocket ASAPS provided survey to board-certied
dures and
surgeries)
expenditures physicians, across specialties with weighted
surgeries
analysis to derive national estimates.

Table 2 identies each data source, with specicity provided to the type of data source, the measures, the medicalized conditions, and the payer.
a
In addition to the Medical Expenditure Panel Survey, the quotation for male infertility arrives from the National Ambulatory and Medical Care Survey, National Hospital
and Ambulatory Medical Care Survey, and the Healthcare Cost and Utilization Project (Meacham et al., 2007).
b
As stated in the text, we theorize this gure for normal sadness is likely as an overestimate, as not all increases between these two time periods can be attributable to the
rise in medicalizing normal sadness. Although hypothesized as an overestimate, our attribution of the difference in expenditure from 2000 to 1990 to normal sadness does
reect an empirical understanding articulated in the work of Horwitz and Wakeeld (2007).
c
The gure for U.S. sales of Viagra was found in a 2006 New York Times citation (Berenson, 2007).

Second, certain treatments were strongly enough associated with

a medicalized diagnostic condition that the treatments, themselves, are used to provide an estimate for the condition. This
estimation technique is used for menopause, male pattern baldness, erectile dysfunction, and obesity. Third, calculations of the
difference in expenditure over time are used to estimate the cost of
medicalized categories that have undergone expansion. This estimation technique is implemented for estimating the medicalization of normal sadness. Horwitz and Wakeeld identify the
expansion of clinical depression to include normal sadness

(Horwitz & Wakeeld, 2007). Sadness is used as a generic label for

normal mild to moderate depressive responses to various losses,
such as bereavement, severe physical illness, romantic betrayal or
rejection, economic misfortune, among others (Horwitz &
Wakeeld, 2007; Wakeeld, Schmitz, First, & Horwitz, 2007).
Therefore, we use the difference of ination-adjusted costs
between 2000 and 1990 to estimate the medical expenditure
associated with normal sadness. To adjust for ination in this paper,
this study uses the 2005 Consumer Price Index, issued by the
Bureau of Labor Statistics (Bureau of Labor Statistics, 2008).

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P. Conrad et al. / Social Science & Medicine 70 (2010) 1943e1947

Results
Our estimate of the total direct health care costs in 2005
attributable to the twelve medicalized conditions was $77.1 billion.
This is 3.9% of the $1.97 trillion in total national health spending for
the United States in 2005 (Catlin, Cowan, Hefer, & Washington,
2007).
The two types of conditions that together make up almost half of
these expenditures are uncomplicated pregnancy and body image
services. Together the size of this bill is substantial, generating
a notable cost to the private and public sector, as well as consumers
themselves (Table 3).
Discussion and implications
There have been concerns that medicalization has been a major
driver of increased health care costs in the United States. We
estimate that the medicalized conditions we could identify make
up $77.1 billion in annual health care spending. This is a relatively
minor portion of national health care expenditures (<4%) and
therefore medicalization is unlikely to be a key driver of spiraling
health care costs. Yet, $77.1 billion represents a substantial dollar
sum. In comparison, $56.7 billion was spent on heart disease and
$39.9 billion was spent on cancer in the United States for 2000
(Thorpe, Florence, & Joski, 2004). The almost four percent of
health spending on medicalization is greater than the three
percent estimated to be spent on public health in 2005 (Budetti,
2008).
Our estimate could be, on aggregate, an underestimation of the
costs associated with medicalization. As discussed in the methodology, we have been conservative in our selection of medicalized
conditions and excluded conditions such as schizophrenia, bipolar
disorder, or bromyalgia, and distinguished normal sadness from

Table 3
Estimated direct cost for select medicalized conditions in 2005.
Medical condition (citation)

Estimated direct
Year of original
medical cost 2005 data source
(in millions)

Anxiety Disorders (AHRQ, 2008)

Behavioral Disorders (AHRQ, 2008)
Body Image (Cosmetic procedures and
surgery) (American Society for
Aesthetic Plastic Surgery, 2008)
Erectile Dysfunction (Berenson, 2007; Eli
Lilly and Company, 2006; Glaxo Smith
Kline, 2005; Pzer, 2005)
Infertility (AHRQ, 2008; Machlin & Rohde,
2007)
Male Pattern Baldness (Anonymous,
1998)
Menopause (Wyeth, 2007)
Normal Pregnancy and/or Delivery
(AHRQ, 2008)
Normal sadness (Greenberg et al., 2003)
Obesity (Bariatric surgery and weight loss
medication) (American Society for
Aesthetic Plastic Surgery, 2008;
Encinosa et al., 2005)
Sleep Disorders (Walsh & Engelhardt,
1999)
Substance Related Disorders
(AHRQ, 2008)
Total

10,878.3
4657.5
12,376.0

2005
2005
2005

1112.1

2005; 2006

1104.2

2005; 2000

1055.1

1999

914.3
18,290.5

2006
2005

6204.0
1341.1

2000; 1990
2005; 2002

1,7684.5

1995

1468.7

2005

77,086.30

Table 3 provides the nal estimation cost for all medicalized conditions in 2005
dollars, disaggregated by condition. All data originally collected in a year other than
2005 have been adjusted for ination the 2005 Consumer Price Index, issued by the
Bureau of Labor Statistics (Bureau of Labor Statistics, 2008).

clinical depression. On the other hand it is possible that our estimate could be also seen as an overestimate because in some cases
not all the costs related to a given condition are due to medicalization. For example, some might exclude the costs of treatment for
insomnia that is secondary to other medical therapy. Additionally,
the gure for normal sadness may be an overestimate, since not all
increases between these two time periods are likely attributable to
the rise in medicalizing normal sadness alone. Although other
factors may also contribute to the difference in medical expenditures on depression between 1990 and 2000, our attribution of the
difference in expenditure for increased medical treatment to
normal sadness aligns with the analysis of Horwitz and Wakeeld
(2007).
More important than whether our estimate is low or high is with
the policy implications of the cost estimate. As we noted above,
medicalization in itself does not connote whether this is good or
bad for health and society, only that problems have moved into
medical jurisdiction. But by estimating a dollar sum the obvious
question is raised as to whether this spending is inappropriate.
Taking this scal concern a step further, it raises the question of
whether policies should be in place to curb the growth or even
decrease the amount of spending on medicalized conditions. While
such policies could be introduced for particular conditions, we
believe such policies are generally not applicable to medicalization
overall. The individual and societal benets would need to be
carefully considered prior to any policy decision to curb or decrease
spending on these conditions.
These policy implications draw attention to the importance of
the economic, social, and political dimensions of health and health
care in the United States. First, there is a notable distinction
between spending by individuals and by employers, insurers, or
government. There is likely less societal concern when individuals
are paying out of pocket for cosmetic surgery or infertility treatment. Second, despite potential societal agreement that normal
childbirth has become too medicalized, we suspect there is unlikely
any societal desire for a wholescale move to the starkest alternative
of childbirth at home with no medical attention. Third, some
analysts have suggested that the pharmaceutical industry is the
major driver of medicalization in an effort to expand the potential
market for their drugs (Horwitz & Wakeeld, 2007; Moynihan &
Cassels, 2005). But individuals with these conditions may
perceive benet from and therefore desire medicalization because
external sources of payment become available when a problem is
dened as a medical ailment.
A next step would be to quantify further the economic and
societal consequences of medicalization. For example, one could try
and estimate the QALYs gained from treatment of erectile
dysfunction or insomnia. In such a cost-benet calculation, medicalized conditions might even be viewed as cost-effective. Future
research might elaborate on these important questions to shed
greater light on the intersections between the social, economic, and
political consequences of medicalization.
There are numerous limitations to our analyses. First and foremost, there is controversy about what is and what is not a medicalized condition. We have attempted to partly resolve this
controversy by using other published studies as a basis for choosing
conditions. Nonetheless, we suspect there will be debate among
readers on whether the twelve conditions were correctly chosen.
Another limitation is that potential off-sets may exist between the
use of health-related direct costs and other non-medical interventions. For example, the provision of medicalized services for
ADHD may deter costs for school-based interventions. These cost
savings to other stakeholders in child health are not accounted for
in this study and remains an area for additional study. Finally, the
quality of the data on direct costs was the best available but is not

P. Conrad et al. / Social Science & Medicine 70 (2010) 1943e1947

without biases due to varied data sources, estimation techniques,

and multiple years of data. Future research would benet from
constructing a stronger cost estimate, specically direct costs for
medicalized conditions from a single data source in the same scal
year.
While we recognize the limitations of this work and the need for
future work to rene our estimates, this initial analysis sheds new
light on the scal impact of medicalization on health care. Although
we nd that these medicalized conditions constitute a small fraction of total health care spending, the expenditures of just over 77
billion dollars provides considerable reason for further attention to
the medicalization process. We offer our cost estimate to advance
the continuing debate and scholarship on the societal and
economic impacts of medicalization.
Acknowledgements
Our thanks to the reviewers and editor for comments on an
earlier draft of this paper.
Appendix. Supplementary data
Supplementary data associated with this article can be found in
the online version, at doi:10.1016/j.socscimed.2010.02.019.
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