Human Limits

Tomorrow is the long awaited election.  What strikes me is that most of the discussion about health care has been about the pros and cons of various flavors of what might broadly be called “insurance reform”.   Who should be covered?  What should be covered?  How do we pay for it?  How is it regulated? What is the balance between the private sector and government be?  Central to all of these concerns are a few big issues:

1. In the U.S. we spend a huge fraction (almost 18%) of our GDP on healthcare and yet our public health statistics are not particularly impressive.
2. The rise in spending on healthcare in general and Medicare in specific is not sustainable.
3. There is a lot of unnecessary spending on procedures and tests – overuse of technology – that probably don’t improve patient outcomes.
4. There are a lot of uninsured people, and there is also a lot of political gridlock.

These are all interesting facts, but to me the current political arguments are mostly missing the bus.

Spending vs Public Health Statistics. 
The determinants of population health don’t have much to do with the formal healthcare (sick care?) system.  I have seen estimates suggesting that 60-80% of population health is about lifestyle, culture and behavioral choices.   So, we need to stop confusing what happens when “people go to the Dr.” with public health statistics.  As I have pointed out in areas like smoking and traffic safety the U.S. has an excellent track record and many of these strategies could be applied to obesity and inactivity.  Also is it fair to compare the U.S. as a whole to smaller more homogenous countries in Europe.   When you match various U.S. states with specific countries, things look different.   Things are not the same in Athens as they are in Oslo, why should they be the same in Miami and Minneapolis?

Medicare Spending.
I have just a couple of comments on the rise in Medicare spending.  At some level doesn’t this represent the problem of “success”?  Every developed country in the world and most of the developing countries in the world are undergoing huge shifts in population structure.     Humans as a whole are living longer and in 2000, for the first time in world history,  there were more people over 60 than under  5.  That having been said,  I would argue that no matter what we do in terms of “insurance reform” for Medicare in the U.S., it is going to be too little too late in terms of finances unless we promote healthy aging.   So again is the problem simply money and resources; or is it really a matter of lifestyle, culture and behavior?  There was an interesting article in the NYT magazine on an Island in Greece with a whole bunch of healthy older people, and the story of these islanders is essentially the same old story for healthy aging.  Don’t smoke, be active, don’t get fat, stay socially engaged etc.

Overuse of Technology.  
The best estimates are that the overuse rate for most things in medicine is about 30%.   The question then is how do you turn this around?   Some argue that more regulation is needed; some argue that electronic medical records will fix it; some argue that the market can fix it.  My guess is that depending on the specifics it will be some of the above, all of the above and none of the above at the same time.   However, why not avoid the need for costly interventions by focusing on the root causes of what drive medical costs in the first place?  I have said it before, the root causes of what ails us are embedded in our lifestyle, culture and behavior.  Why not focus on these issues?

The Uninsured vs. Political Gridlock.
Among the many things I find ironic about the political debate on healthcare reform is the fact that the individual mandate in Obamacare was originally developed by conservative thinkers.   Along similar lines ideas about premium support now championed by Paul Ryan (e.g. vouchers) were initially developed by liberal policy wonks.   Go figure?   How will we ever address the issues of the uninsured, costs, overuse of technology, obesity, inactivity, aging and everything else associated with healthcare if policy ideas are merely ropes in an ongoing political tug of war?

Is there a solution?
I think in the short and medium run we should all do two things:

1. Take responsibility for our own health by following key guidelines that I have discussed over and over again in my posts.
2. Indicate to the political leadership that focusing on public health initiatives might be a good (and cheap) first step they could all agree on.

If we all did these two things maybe that would give them some time to learn that thoughtful compromise on the other issues will not be fatal and pragmatism is not a disease.   Denial can be both.

This entry was posted on Monday, November 5th, 2012 at 6:35 am and is filed under Current Events, Health Policy. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.