Health Care: Wellness not Insurance Reform
WASHINGTON – Oddly enough, the initiative aimed at reversing children obesity in the US just presented by Mrs. Obama is the only health care related plan on the table that looks at the issue of “health” comprehensively, with the objective not just of “curing” a disease but of promoting good education that will have enhanced “wellness” as the outcome. Indeed, the objective is the well being of children across the board. Hence the need to look at everything that impinges on this goal: proper nutrition, ability to distinguish between healthy food and junk food, amount of sedentary time spent in front of the TV, amount of physical exercise, incentives or disincentives towards a healthy life coming from the family, schools and social interactions. The point made by the First Lady is quite simple. It takes long term, sustained action on all of these fronts, resulting in a serious course correction, in order to have healthier children as the end result. She also pointed out that healthy children growing to be healthy adults will need less medical care later on, as they will not be affected –at least not to a high degree— by diseases normally associated with unhealthy life styles.
Health Care at the beginning…
While the objective is huge and while the need to create and sustain a multi-pronged approach aimed at helping millions of children affected now by a veritable obesity epidemic, so that children will learn and maintain a healthy life is daunting, clearly this program contains the substance of what had been dreamed about while presenting the brand new “wellness approach” that was discussed in the early days of the Obama administration. A “wellness” goal, not just health insurance reform, was supposed to be the real game changer, the necessary and indeed overdue reappraisal of the health care issue finally bringing to the light its real constituent parts. It was said then that we really wanted to change “the system”. No longer health care as the mere delivery of services to sick people; but a layered approach aimed at creating awareness of what it takes to be healthy and stay healthy in the different stages of life.
Nobody really said that this way we would abolish the need for medical treatments; but it was rightfully argued that people leading healthier lives, on balance, would need less medical remedies. Whereas a population of millions of Americans who eat poorly, who do not exercise and who are addicted to toxic substances are more likely to need more care, as their unhealthy life styles will make them more vulnerable to disease.
The revolutionary approach is gone
Simple stuff. Intuitively obvious. But what happened to this lofty, maybe ambitious but essentially correct approach? Who knows, really? It’s gone, essentially forgotten. Instead of talking about a revolution in the very concept of health care, we have narrowed the debate down to a discussion about medical care cost, and, even more narrowly to a debate on medical insurance availability, portability and cost. Not that these are unimportant points; but debating them without addressing the larger context of which they are essentially the byproduct, rather than the cause, is not that useful. Lacking a wellness goal as the real strategic game changer, (initially promised and then silently dropped), the health care reform package pushed by the Democrats, whatever its chances of passing, due to the added problem represented by the recent loss of a key Senate vote, is still a bad idea.
This reform package will not work
It is a bad idea because, despite the good intentions regarding covering millions of uninsured and increased affordability for millions of others, this reform package does not really address the truly perverse systemic flaws of a health care system that is set in motion only when (often preventable) issues have become medical problems to be fixed. On top this, the system is fatally geared to “overdo” in terms of quantity –and therefore cost– of services ordered by doctors to their patients. These systemic shortcomings, added to a population that is on average increasingly unhealthy because of widespread bad habits regarding nutrition and exercise affecting millions of Americans, provides the ideal formula for runaway health care costs.
Keep repairing a poorly maintained car
It’s like having a car that is left out in the cold, that never undergoes scheduled maintenance, not even oil changes. This car is more likely to develop problems that will need to be fixed by an auto mechanic. Of course, the auto mechanic will be delighted to observe that the owner does not take care of the vehicle. The worse the every day care, the more likely the need for more visits to the workshop, more fixing and more repairs. Does the auto mechanic have any economic interest in advising the car owner on basic principles of preventative maintenance? Probably not; as lack of good vehicle maintenance aimed at avoiding major breakdowns, while preserving a state of “good vehicle health” is the source of additional income for him. In addition, as the auto mechanic knows that the bill for his services is not paid directly by the car owner but by a “breakdown and repairs insurance policy”, he feels that he does not need to say anything to the ignorant car owner, so that he will keep coming back for more and more expensive repairs.
We fix only what is broken
In essence, this is the problem of US health care. It is mostly “care after the fact”, with little or no concern about how to help people stay healthy, thus preventing or mitigating the impact of at least some types of diseases. Beyond that, the insurance system, as currently configured for those who are covered, shields the majority of the population from bearing the direct impact of the cost of procedures ordered by busy doctors.
The individual and/or his employer pay for insurance and the insurance takes care of the medical bills. So the “customer”, (just like the imaginary car owner who goes to the auto mechanic with insurance coverage), does not feel directly the financial impact of whatever the doctor may order. But a cost is nonetheless incurred. Eventually, when cumulatively the cost of all procedures, including all the unnecessary ones, covered by an insurer gets to be too high, the insurance company will jack up the insurance premium, to the dismay of the individual customer or the employer who provides the insurance itself.
True, the health care reform package currently on the table in some fashion tries to address the issue of what should be proper care, best practices, cost effective procedures for common medical issues, other measures aimed at diminishing administrative costs and the like. But, as currently conceived and presented, it does not really aim at transforming the fundamentals that conspire to have a system that overprescribes, while doing nothing to promote wellness for the general population.
The providers’ interests
Cynically we could say that this is simply because the medical/pharmaceutical industries have an economic vested interested in having as many sick customers as possible. If we look at the issue in purely economic terms, right now the industry “wants” people to be sick; in as much as it is only sick people who need medications and procedures; while comparatively healthier people need much less. In a health care system in which my doctor makes money only if I am sick, what is his financial incentive in keeping me healthy so that I can avoid sickness and the consequent costs (his gains) related to fixing it?
If we do not address head on these systemic flaws, regarding the lack of incentives to provide wellness education and the “fee for service” approach to medical care billing an payments, the only way to contain the cost is to ration one way or the other the amount (and thus the cost) of available care.
Yes, it is all about “wellness”
It has been said before; but it is worth repeating that the US needs a comprehensive approach to “wellness” aimed at vigorously encouraging and promoting healthy life styles. It is odd, in fact, almost incomprehensible how the US, the biggest economy on earth, with a variety of first rate medical research facilities, with developed educational and mass communication tools, cannot correct the mess caused by a fundamental lack of care regarding education about the fundamentals of a healthy life style. We have the knowledge, we produce the research; and yet we cannot apply it to ourselves?
Present system: lousy outcomes
And what is the end result? Very poor. We have the highest medical costs in the world, both in absolute terms and per capita and in the end America’s broad health statistics are mediocre to poor. Indeed, with all our incredible health care expenditures, if we look at life expectancy at birth, the US, the biggest economic power in the world, ranks at number 49 in the world; right between Portugal and Albania. So, this is what an aggregate spending of 16% of GDP, (and rising), on health care gets you: the life expectancy of Albania! And this happens in the US. All the talent produced by the best business schools and top notch schools of public administration somehow has not managed to notice that, at the very least, this system is not cost effective.
Yes, there will be sickness; but less
It is obvious that healthier life styles, while certainly not enough to “abolish” sickness, can reduce it significantly and consequently reduce the economic weight of health care delivery. Let’s think for a moment at the explosion of cost related to the consequences of the obesity epidemic. Clearly this is only one part of a larger picture; but it is a significant part, worth hundreds of billions of dollars, year after year; because diseases like diabetes or hypertension are chronic and need continuous monitoring and treatment.
The tobacco experience
In the US we have spent years and considerable resources to fight tobacco head on, on the basis of the unquestionable knowledge that, on average, smoking is a significant health hazard. A hazard bad for the individual smoker, for the people subjected to the effects of smoke around them and bad for a health care system that is called upon to treat the consequences of the smoking habit. But, if this is so, it should also be obvious that, in a slightly different way, unhealthy food in the supermarkets, bad eating habits, lack of proper exercise, the widespread abuse of alcohol and/or other toxic substances contribute to the nurturing of a population more at risk of developing diseases.
Education can prevent disease
Given this dire picture, real reform would have to include a serious approach towards wellness education, while it would have to include a transformation of the financial remuneration for the medical profession, so that the perverse incentive of always doing “more”, because “more”, means more money for the physicians, is abolished –once and for all. In a truly reformed world doctors should be a lot more than just “mechanics” who fix your body for a fee once you walk through their door because you need repairs. Doctors and nurses should be an integral part of a multi-pronged educational apparatus aimed at teaching and spreading good habits, so that people develop healthy life styles and thus stay healthy.
Let’s be clear, wellness education, physical exercise, good nutrition are not going to abolish diseases. There will be issues due to heredity; there will be cancer; there will be accidents; broken legs and worn joints in need of replacement. But we can safely bet that the volume of demand for health care services in terms of treatments will be reduced. With diminished demand and a different way to reward financially the medical profession, the economic pressure on the system, whether based on private insurance or on anything else, will be lessened.
A tall agenda
I do realize that, as ambitious as the Obama plan was and is, what I propose is far more ambitious and thus more complicated, with no immediate gains. The difference is that my approach attacks the problem at its roots; whereas what is on the table right now does not. What we have on the table is an honorable attempt to provide services to millions of people who are left out. But the notion that it can provide care without adding to the overall cost, not just now but in the years to come, is a fantasy. When it comes to these types of services, given the underlying, perverse “inflationary” incentives that will remain essentially untouched, the tendency will be for aggregate costs to go up and not down.
The First Lady gets it right
As noted at the beginning, strangely enough, the just announced First Lady initiative on child obesity, conceptually at least, looks a lot more promising. True, we may agree that this is the “soft” side of health care. We may say that this is a worthwhile, noble cause fit for the First Lady. Something that can keep her busy and that can allow her to go around preaching a good Gospel of good habits, etc. People will listen, and will nod politely. The impact of all this in the end may be minimal; but there will be the satisfaction of being on the right side of the issue, with all the accrual of moral capital that this may bring along.
And yet, if we dream for a moment and we think that this initiative can have real traction, that it will be seriously endorsed by all the relevant stakeholders, thus rapidly changing habits and thus the basic conditions for millions of overweight and obese American children, well, this initiative would be the closest thing to a real and comprehensive approach to wellness.
This would be a real, meaningful contribution to making Americans healthy and thus, down the line, not so much in need for health care services necessary to fix the effects of a bad life style. If we could indeed imagine for a moment that, magically, in a short period of time, millions of overweight children could be “normal”, not just in terms of their weight, but also in terms of their fitness and all the habits that contribute to normal weight: such as healthy, nutritious food, plenty of fresh air and good exercise, we could safely assume that this would be a much healthier generation that will stay healthy for much longer and that overall would require comparatively less in terms of medical services.
Can we forge a new consensus on wellness?
But it would take a miracle to successfully sell this comprehensive approach to all the parties that have an interest in the health care reform debate. Right now, health care has become a poisonous topic, likely to ignite partisan, acrimonious fights that go way beyond the merit of individual issues contained or not contained in the package. Right now, it is raw politics. To have President Barack Obama fail on this, means humiliating the Democrats and showing that the opposition has real teeth. So there. The health of the American people does not come into this perspective; not even as an afterthought.
And it may very well end up like this. A huge mess laced with posturing, animosity and wild allegations. In the meantime, we shall continue to limp along with a horribly inefficient, damaged and stupendously expensive system; while the overall health conditions of the average American, (unless you are a millionaire who can afford the 5 star treatments at the best private clinics), will not improve a bit. And this is really sad. We Americans are supposed to be pragmatic problem solvers.
What happened to Yankee ingenuity?