WASHINGTON – The US health care delivery system, as currently structured, is so horrendously expensive that over time it will bankrupt the country. On top of that, because of a lack of meaningful “upstream” efforts focusing on prevention and “wellness education” for the general public, this system, as expensive as it is, at best is capable of treating disease after its onset. So, a lot of money devoted to help people already in bad shape. And almost nothing to help prevent life style related diseases.
US health care amounts to an extremely inefficient, incomprehensible, (at least for the average citizen), hodgepodge resulting from lack of focus on prevention, perverse financial incentives for doctors to over prescribe unnecessary and, in some cases, evenharmful procedures, so that aggregate haelth costs are inflated; an unsustainable private insurance system; an equally unaffordable public care system, all nicely blended with progressively more and more unhealthy life styles mindlessly pursued by tens of millions of Americans who have not been taught that a combination of healthy nutrition, plus a modicum of physical exercise will yield in most cases better health and improved quality of life as a likely consequence.
Public policy: just mitigating the consequences of a bad system
Public policy tries to manage somehow this ill conceived system; but only timidly and without having laid out a clear strategy focused on “wellness” as the desired paradigm that could in turn be embraced by the larger population. The focus of the Obama administration in the long and divisive debate on health care reform was mostly on expanded access to health care, a worthy cause in a modern country in which millions of people do not have any form of health insurance. But the almost exclusive attention on availability, access and affordability of health care insurance when a person becomes sick overshadowed the critical issue of what should be done to drastically diminish aggregate demand (and thus the national cost) for health care services. The really crucial focus on healthy life style, (this is real prevention), as a key factor that will drive down demand (and thus aggregate cost) for health care services is missing. It is intuitively obvious that millions of people who lead unhealthy lives will develop more complications and thus they will need more health care.
Cutting Cost? Wishful thinking
So far, government attention has been on trying to pursue two parallel but in my opinion mutually exclusive objectives: a) increasing health care coverage; and b) attempting to lower cost for the system overall. The first one may be on track. The second? Well….who knows. Too early to tell. We shall see how the recent health reform package will be implemented over a number of years. For the moment, the stated goal to begin a process that will constrain health care costs remains a worthy aspiration, entrusted, however, mostlyto experimentations, reviews, analysis of best practices, etc. Well….good luck with the idea of saving real money with this approach.
Public health care spending: unsustainable
At a closely related level, no serious discussion about US fiscal policies and serious deficit reduction strategies can take place without mentioning the ballooning cost of the public portion of health care. As Lawrence Summers, Director of The National Economic Council at the White House, reminded a Washington audience just a few days ago, the public share of health care alone, (which is only one component of total national outlays), if left on its current spending trajectory, will keep growing so much that it will eventually gobble all federal revenue, leave nothing for other spending, and ultimately bankrupt the US.
Growing cost of health care considered inevitable
This is pretty serious stuff. And yet, whenever policy makers, including Summers, talk about overall health care costs they talk about them as a “given amount”, if anything inexorably poised towards unstoppable growth, impervious to any dynamic that may bring them down. In other words, policy makers say: “This is our current and projected cost for health care. This is the hard reality. We have a national agreement whereby government will bear a substantial part of this cost. Let’s see how we can manage to sustain this burden.” No serious investigation as to the factors that brought us here and whether or not they can be changed so that the upward spending curve will be modified.
No connection in public policy debates between life style and public health outcomes
Indeed, are these health care costs the equivalent of a law of physics, a natural phenomenon beyond our control? Not really. In fact, looking at the experience of other modern countries, we discover that there is something inherently wasteful with the system that we created to treat Americans. Strangely enough, in this country of science, innovation and legions of experts on diet, exercise, nutrition and any other possible fad about healthy living, it turns out that most people do not practice any of that. Most people live rather unhealthy lives. They eat on balance mostly bad food and too much of it; and they do not exercise. When these bad habits lead to disease they go to see a doctor. Just like the FBI gets into the scene only after a crime had been committed, so doctors come into the scene to fix what is broken. No robust system in place to prevent at least some common diseases related to life style and thus prevent and avoid costly treatments, medication and procedures.
We spend massively and get poor results
To put all this together, America as a nation spends stupendous amounts of money, now above 15 per cent of our GDP, to treat diseases that in large part are preventable –in as much as these are ailments that millions of Americans brought upon themselves as a consequence of a very unhealthy diet and lack of physical exercise.
As a consequence of this blending between high cost of health care and high demand for services by people who are in bad health and therefore need disproportionately “more”, we have this most remarkable American contrast of the highest health care bill in the world and at best mediocre health conditions for the general population.
The explosion of obesity, with all its negative medical consequences for millions of Americans, including now an alarmingly high number of children, is only the most visible manifestation of this deterioration. So, the baffling issue is lots of money spent and mediocre results. Indeed, with all these fantastic sums of money and a huge percentage of national wealth spent on health, on average one third higher than what other rich countries spend, one would expect better outcomes. Not so. We have very little to show for the money devoted to health.
US life expectancy is close to Albania and Portugal, hardly case studies in health care systems excellence. Sure enough, the US has some of the most advanced health care facilities in the world. Fine. But this means only that, if you are very rich, you can get the best of what medicine can offer. Yet, this says nothing of what is available, on average, for the average citizen. And again, if the average citizen does not nurture his/her health, medications and procedures whatever their cost can only get so far.
So we have an odd combination between a system geared to spending more rather than being attentive to the cost-effectiveness of care and people who need much more than their peers in other modern countries simply because they do almost nothing to prevent otherwise preventable diseases.
Medical care: the problem of “fee for service”
The incredibly high level of spending in the US is due to the perversion of having a system almost entirely based on incentives to providers to do “more” of everything, necessary or unnecessary, as it may be, unfortunately combined with a population that has a high demand for health services. A recent, detailed AP story (“Overtreated: more medical care Is not always better”), indicates that: “Anywhere from one fifth to one third of the tests and treatments we get are estimated to be unnecessary”. Up to one third unnecessary? Can you imagine how many billions of dollars that is? Dr. Daniel Goodman, of the Dartmouth Institute for Health Policy, quoted in the same story, indicates that doctors may have good intentions. Yet:
“We also live in an environment where there are strong financial incentives to deliver certain types of care. We get well paid for doing procedures. We get paid relatively poorly for spending time with patients and helping them make choices”.
Got that? There are “incentives”. “We get well paid for doing procedures”. And many of them, it turns out are unnecessary of even harmful, (witness the exorbitant number of babies delivered by cesarean and the casual over prescription of antibiotics for almost anything). So, at least economically speaking, this set up has been paradise for all health care providers. As Dr. Goodman confirms, physicians get paid not for keeping you healthy but for fixing you when you are sick. And, in so doing, any sickness, deliberately or just by force of habit, gets to be milked for whatever it can yield in terms of procedures, surgeries, hospital charges and prescription medications.
From this we get the horrible yet inescapable conclusion that most doctors, as the system is currently conceived, (even allowing for the presence of at least some ethical persons within the medical profession), have no economic interest whatsoever in promoting healthy living. In fact, the more unhealthy the personal habits of millions of Americans, the more prosperous their medical practice will get. Sick people need medical care; healthy people do not. And doctors are not rewarded for keeping people in good health. But, in the end, as noted above, this trend will end up eating most of our national resources. Thus it is unsustainable.
Doctors as salaried workers with no personal incentive to over prescribe?
We know that there are practices in the US in which physicians are salaried workers whose personal financial gain is not tied to the number or cost of procedures that they recommend and that patients, knowing no better, accept. But, if we look at the “fee for service” prevailing standard in conjunction with a progressively more unhealthy population due to extremely bad personal and dietary habits, then the picture becomes something like a grotesquely hellish workshop. America’s health system is a money making machine predicated on the inexhaustible supply of “patients” provided in large part care of the consequences of bad eating habits kindly encouraged by the major food companies and fast food chains that constantly promote tasty but long term unhealthy stuff goobled up in industrial quantities by unaware people.
The “Western diet”
And let’s look at those habits. As Michael Pollan noted in his book “Food Rules, an Eater Manual”, we in the US have somehow perfected the worst possible model of unhealthy diet. The “Western Diet”, as Pollan calls it, consists primarily of highly processed foods, artificially enriched with sugar, other highly caloric sweeteners, fat and salt. Most of the food stuff Americans choose from when shopping at the supermarket or eating in any fast food franchise falls into this category of highly processed, highly caloric and not very nutritious items. Overtime, a diet made of predominantly processed food, consumed in large quantities because it is cheap and tasty, becomes a large factor in the onset of many otherwise totally preventable diseases: such as diabetes, certain types of cancer and circulatory problems, in turn causing heart attack and stroke, and many more.
American creative genius gave us junk food
Call it the outcome of our creative genius. Some people invented microchips, high performance jet engines, robots and internet applications. Others invented and refined alluring ways to feed us inexpensive sugar loaded sodas, bars, potato chips and other snacks consumed in industrial quantities by most people. The funny outcome is that, by inventing and successfully marketing a diet sold to the public on the basis that it consists mostly of cheap, easy to serve food, we have slowly poisoned ourselves. So, we have saved grocery money gorging on cheap snacks and fast food. In truth, purchasing better quality fresh food would cost more. But then, down the line, much more money is spent by the nation as a whole to treat chronic diet related diseases like diabetes that could have been prevented, with significant net gains for both the health of millions of Americans and the national pocket book.
We still need health care for normally occurring disease
This is not an attempt to oversimplify a complex health care picture. It is obvious that plain old “real” sickness does and will exist and that we have to do our best to meet the needs of those in need of health care. But surely there is a great deal that we should do to nurture healthy habits so that people will be on balance healthier. The difference between caring or not caring for our national wellness translates into a better or poorer quality of life for millions and literally hundreds of billions of dollars saved because millions will no longer need diabetes or high blood pressure treatment.
The medical consequences of bad diet
Again, according to the synthesis provided by Pollan at the beginning of his book on proper nutrition: “Virtually all of the obesity and type 2 diabetes, 80 per cent of the cardiovascular disease and more than a third of all cancers can be linked to this [Western] diet”. Based on his research, Pollan also indicates that, according to existing studies, while the damage caused by bad diet manifests itself in otherwise preventable disease, if and when people have the opportunity to go back to a healthy diet based on vegetables, fruits grains and protein, their chances to keep their health grow significantly. “In one analysis –says Pollan—a typical American population that departed even modestly from the Western diet (and lifestyle) could reduce its chances of getting coronary heart disease by 80 per cent, its chances of type 2 diabetes by 90 per cent and its chances of colon cancer by 70 per cent”. These are huge percentages.
Nutrition, wellness and lower medical bills
Well, I do not know whether the data collected by Pollan and provided in his book is totally correct. But even if it is somewhat exaggerated, this correlation between bad diet and disease has been noted and documented before. It is obvious that nutrition and life style should be front and center in any serious discussion about the promotion of wellness. And it is almost intuitively obvious that well crafted wellness regimes should keep people on balance healthier. And from this follows that healthy people will need a lot less medical care, thus causing huge savings and the shrinking of our national medical bills.
Unable to fashion a national wellness strategy
And yet, while these facts and their connections are known: a) a bad system of incentives to doctors so that they will over prescribe; b) the disconnect between wellness promotion and health care; c) the disconnect between healthy nutrition and wellness; somehow we have separate conversations for all these issues, as if they were discreet problems and not part of one important continuum which should be called: “Understanding the value of being healthy, the habits to be cultivated to stay healthy, and the role that should be played by all health care providers to foster wellness for all, as opposed to treat disease after its onset”.
Disjointed information: no clear picture provided
For example, a recent, quite prominent, story in the “Personal Journal” section of “The Wall Street Journal” featured the health problem of deteriorating arteries and what that means in terms of the onset of heart disease and a variety of other circulatory problems. And yet in this story that describes in some detail diagnostics, while providing all sorts of other medical information, there is only brief and passing mention of the most obvious cause of arterial deterioration, i.e. bad nutrition and the consequent increase of cholesterol deposits in the arteries. No clear message coming out of this article saying: “Well, this is the problem. Now, as of today, dear reader, you commit to change your diet and you will greatly improve the conditions of your arteries and your chances to live a longer and healthier life”. None of this. And this is just one example.
As in the article mentioned above, health care debates are mostly focused on issues related to health care delivery. Costs are examined separately, as they are deemed to be the stuff of health care economist and or/public policy specialists who have to figure how these costs fit into existing and future programs.
Nutrition information is mostly about being thin and beautiful not about being healthy
More broadly, there is no serious national debate about a better way to re-conceive the medical profession, its proper function and its just remuneration within a national “wellness program” aimed at preventing diseases, rather than just dealing with their consequences and costs. By the same token, nutrition, while a popular subject, is mostly featured in faddish diet discussions focusing on the fastest way to lose weight as an esthetic and not a wellness goal. Being fat is not chic. People in Hollywood are thin. But if you and millions of others do not care that much about being thin so that you can go to Hollywood; if you are not that keen to give up the pretzels and the beer in order to shed 20 or 30 pounds, and thus you have given up on the idea of looking like a movie celebrity, that is the end of that argument. Not much is being said about healthy food because it helps you stay healthy. And, yes, healthy food will also help you lose weight. But the key message should be that eating healthy stuff strengthens your health and not that weight loss should be pursued so that you can look beautiful.
Health care reform may be in place; but we are still unhealthy
And so, while the various dynamics –exponential growth of cost, “fee for service” incentives to over prescribe, bad diet and life style and their consequence on health—are known, somehow no one in a position of authority has bothered to put all this together under the banner of a positive “Wellness Strategy” for America.
President Obama takes pride in having signed into law his health care reform bill. But there is not much there about wellness. Until we get to the point of formulating and then, as a nation, embracing such a strategy, we shall continue to have half measure and timid steps, while people will lead unhealthy lives and medical costs will continue to rise. Not a very good prognosis.