The Battle over Health Care - NY Times

One way we could all "save money" would be to stop putting oil into our cars. Of course, then we would have to deal with the "high cost" of replacing engines, the long waits at engine repair shops, etc. And we could have national programs to cut that cost down by 20% or so. So, we could save the $15/year we spend on oil, and replace it with $1,500 a year in engine replacement costs.

I am hoping that most people would see that the "money saving" scheme above is a terrible idea. What's remarkable is that, when we shift to health care for our bodies, everyone seems to be arguing about reducing the cost of engine replacement and what kind of insurance should pay for it. The idea of preventing the problem in the first place somehow got lost in the shuffle.

In a fascinating editorial today titled "The Battle over Health Care" the New York Times compares candidates platforms and seems something missing. The editors state:

WHAT’S MISSING

All of the plans, both Republican and Democratic, fail to provide a plausible solution to the problem that has driven health care reform to the fore as a political issue: the inexorably rising costs that drive up insurance rates and force employers to cut back on coverage or charge higher premiums. All of the plans acknowledge the need to restrain costs, but most of the remedies they offer are not likely to do much.

Electronic medical records to eliminate errors and increase efficiency, more preventive care to head off serious diseases, and better coordination of patients suffering multiple, chronic illnesses are all worthy proposals, but there is scant evidence they will reduce costs.

Well, I beg to differ. Adding oil costs way less than replacing engines. Preventing disease costs way less than "fixing" it. And yet, of every hundred dollars spent on "health care" in the US, less than $2 is spent on such prevention.

What it seems to me "is missing" is a serious discussion and investigation of exactly why and how we have, as a nation, become so blind to the obvious. And, why is this defect in our national perception resistant to any learning curve?

Since everything decays, including resistance to learning, something must actively be replenishing this social myth. Something like, say, today's NY Times editorial?

I don't want to spend today's column presenting evidence for the value of preventive care, except to note that your sense about oil in your car is correct. Maybe when I get done I'll add links to authoritative sources on preventive care. I've argued that before.

It is an astonishing fact that half of all increases in life expectancy in recorded history have occurred within this century and that most occurred in the first half of the century, before the introduction of modern drugs and vaccines. (Harvard University)

What I do want to do is look at the cultural and psychosocial factors that have created this blindness and that sustain it in the face of overwhelming contrary data.

Off hand, there are a number of contributing factors that spring to mind:

• Clinical health has far better marketing than public health
• Public Health is, effectively, clinically depressed
• Most players on the receiving end of the cash flow don't see the cash flow as a problem.
• Prevention is distant in space and time from the engine-failure event
• It's very hard to count events that would have happened but didn't
• It's very hard to "take credit" for successful preventive maintenance.
• Really good preventive maintenance staff tend to be fired, since "nothing ever breaks, so who needs them!"
• It's very hard for any politician to invest in efforts today that won't bear fruit until a decade from now, regardless how big the fruit is.

We can disentangle these factors somewhat more. Some of them are "perceptual" problems, where even good scientists lack good tools to see, let alone measure, what's called "distal causality" -- that is, causation far in time and space from events, or even harder, an absence of events.

THERE! DID YOU SEE THAT thing that just didn't happen! Just then!
LOOK! It didn't happen again!

Nope, we're not wired that way. Still, people can understand about putting oil in the car. What's different about health care?

A major factor here, generally not considered polite conversation, is a running battle well over a thousand years old between public health and the advocates of prevention on one side, and clinical health and the advocates of heroic acute repair on the other. Those receiving the money tend to argue that they are not biased by this cash flow, contrary to everything known about clinical trials and the insidious effects of bias on judgment. It certainly takes the punch out of arguing that the best "final state" to be desired, socially, would be the degrading of importance of hospitals and doctors or the elimination of both entirely to an era we'd all rather forget when people didn't know how to stay healthy.

I'm not saying that investing in public health would eliminate doctors, but it would certainly refocus them and you'd have to go well against human nature to expect them to be setting up as a national end-goal their own elimination as a respected and rewarded group. So, silence from the American Medical Association on this subject can hardly be viewed as an biased judgment call. And, to be fair, the AMA just elected a Dr. Ronald Davis, a preventive medicine specialist as president, so I suspect they know this change in focus is inevitable and are already reluctantly starting to prepare for it and shift focus to prevention and quality improvement and actually tracking "outcomes." At a recent talk at a Global Health Preparedness conference at the University of Michigan, Dr. Davis emphasized the links between public health and the AMA and his intent to build new bridges between the groups.

Amazingly, however, we don't hear the insurance industry advocating greater prevention efforts. I've inquired about this, and apparently they make money on transactions, not on keeping people healthy, so the corporate bias would be to want more transactions, if you get my drift. They aren't financially motivated to eliminate their source of revenue (broken engines.)

And public health mostly talks to itself, kicking the cat and muttering about how nobody loves them and there's just no point in talking, so have another drink and live with it. Their silence is actually probably due to a lack of funding for good media campaigns, as a result of the last 100 years being kicked across the schoolyard by the AMA and the insurance industry and other beneficiaries of the cash flow. I don't think "clinically depressed" is too strong a term for the state of the field. Most of the improvement in life-expectancy in the last century was due to public health (clean water, sanitary sewers, hand-washing regulations in restaurants, refrigeration, etc.) and occurred prior to the explosion of hospitals, following the Hill-Burton Act, in 1946, as well as prior to the explosion of use of antibiotics.

That, incidentally is a problem now, as antibiotics are increasingly reaching the end of their useful lifetimes, and the long-term result of their use has resulted in "super-bugs" like MRSA and VRE. Suddenly we see "infection control" moving back onto the radar screen, in hospitals and nationwide. We might, gasp, even expect to see a massive media campaign on the concept of washing hands after using the toilet, although if it happens it will most likely be paid for by public health, not the AMA, which still can't even persuade all their own doctors to wash their hands regularly.

Meanwhile, cholera is breaking out in Baghdad I see by the news, since the US blocked the flow of chlorine to public health facilities there, so water treatment with chlorine to kill cholera has stopped - something we just take so much for granted in the US we forget it is there.

So, there are issues with how humans perceive causation, compounded with power politics around a truly huge flow of cash - larger than the defense department, larger than oil. There is a huge invisible effect of bias blinding most doctors, who are generally good and caring people as individuals, to the true magnitude of this problem. (By the time they are done with med school, they're trapped in the system.) Trying to make a living as a "family doctor" in the US today is a losing proposition, totally underfunded as one of the front lines in prevention. So, the nations problems pale in light of the larger, more tangible, personal cash flow problems of just making a living in an insane system gone haywire and dysfunctional.

Public health academics mostly just talk to each other, although that's a common trait for academics in general. There is a dawning realization that no one in government or policy making positions is listening to them any more, and some movement to try to figure out how to have more clout -- hard, since most public health workers in the US are at or near minimum wage since the field is so misunderstood and devalued by the population, in a self-latching loop.
(No cash = no advertising = no cash, etc.)

Meanwhile, since no politician can educate the public against this tide of confusion, and they can't hope to benefit from getting credit now for investing in prevention of future things that won't happen in someone else's term in office, we can't expect much from them.

Still, I did expect more from the New York Times, than not realizing the value of prevention.
At least they could have said "There is scant attention given by us and other media to the overwhelming body of evidence that prevention would save well over half of our health care costs" and done a research piece on why that is.

Probably the last psychosocial fact I didn't mention is relevant there. Prevention would require that people "shape up" and let go of bad behaviors and adopt healthy behaviors - and that would seriously cut into both the profits of some big industries (tobacco, fast-food, alcohol, etc.) and ask people to take personal responsibility for their own "outcomes" instead of the philosophy of "party today and regret it tomorrow" that has become so prevalent.

Again, that could be fixed, but there are strong financial interests in not fixing that aspect of American culture. We still want "mature" to equate to "irresponsible." It may be fun, but other countries with less of that will be eating our lunch soon, and that won't be fun.

GM is blaming its woes on health care costs. According to Harvard's researchers, the largest single cause of bankruptcy in the US is medical bills. Changing who the middleman insurer is for this process will simply change the letterhead on which you get your bill for the engine repairs of yourself and your neighbors, but won't lower the bill.

Nothing will actually lower the bill until we "do less of that" and switch from a repair-mentality to a prevention-mentality. That would be worth about, literally, a trillion US dollars a year, but would require about a billion of that going to revitalize our champions in public health. ( You'd think this would be worth 1/200th of the $200 billion we do choose to spend on the War in Iraq next year in order to make us all "safer" and more secure from bodily harm. )

The fact that we, as a nation, can't do the math and see that trade-off is not helped by today's New York Times. I had hoped for more. I suppose we could dig one more layer further upstream and ask why the Times can't get its own research together anymore.

Meanwhile, looking in our own mirror, on a national scale dawn is coming, the party's over, and the guys with the bill are at the front door. I can't help but notice that neither the grand state of Michigan nor the US Congress has managed to get a budget together for the new fiscal year, that starts in a week. It's the first day of fall and summer is over. Nobody seems to want to face the music and look at the mess we've made for ourselves.

It will be more obvious when the Michigan government shuts down in a week, and the Federal government shuts down in mid-November (judging from prior times they've pulled this stunt.)
Still, it won't do much to improve our image internationally as the guardians of the world's "reserve currency." Or maybe, we've abandoned that role too.

But, here's one suggestion for the UAW - if you guys take on that $50 billion retiree health care obligation that GM is offering you, check out this idea of "prevention" and make friends with "public health." If we can't get the cost of health care in the USA under control, that trickle of patients heading out the door (with their money) to medical tourism sites abroad is going to turn into a flood, and there goes another trillion dollar a year industry outsourced to Asia. Then no Americans will have any money left to buy GM cars, because their medical costs will be hemorrhaging into pockets abroad.

It's like "fuel efficiency". This isn't a local issue any more. It's a global competitiveness issue. If we don't fix it, customers will stop coming entirely. Hospitals need to emulate Toyota and get "lean" about their costs in doing defect-repairs ("health care"), but the whole US needs to get "lean" and stop passing the defects downstream to hospitals and start fixing them upstream at the source, for the very same reason - the economics are killing us.

And, meanwhile, hospitals should consider a different long-term strategy than simply being superb at fixing the defects that are passed on to them by failures upstream in the nation's public health system, as that only institutionalizes the large-scale system structural problem and costs.

Hospitals need to transition increasingly to having positive value-adding roles, not just defect repair roles. They should consider being at the forefront of physical and mental and social fitness, and building our capacity to cope with life and build innovative and thriving industries, not just cleaning up the breakdowns and depression that come from failures in those areas. Then, their success is aligned with our success, and odds of long-term survival of all of us is improved.

Of course, if Hillary Clinton is reading this, remember that one rule of "lean" is that you have to guarantee the employees that, if the cooperate in making things run better, they won't lose their jobs. They may have different jobs, but they won't lose their jobs. Ditto for hospitals - if they participate in reducing their defect management role somewhat and support fitness enhancement programs instead, they need to be guaranteed no one will lose his or her job.

As always, the focus must be on the "customer". And as always, there is a hierarchy of customers, from individuals to families to teams to departments to companies to states to nations. If we do this right, it should be a win-win-win-... etc for everyone. Fit and healthy and innovative employees are what our companies need to thrive, and vice versa.

The job of public health should be to catalyze that win-win transition, and break the "us" versus "them" logjam, of "either" individual fitness "or" corporate fitness. Let's do the "and" solution instead!

Wade