Most of the "health care" system in the US, the part not swept up in keeping track of who is paying, is consumed with finding every faster and better ways to deal with gunshot victims.
The focus of "public health" on the other hand is to walk outside and ask, "Why are so many people getting shot, and what can we do to stop that from happening in the first place?"
The "health care debate" in the US today seems to be focused on heated debate about which insurance scheme will be used to pay for better gunshot treatment centers, what order will the victims be treated in, and whether some gunshot victims should simply be refused treatment.
We need to stand further back and go, "Wait. Why do we need ANY gunshot treatment centers at all? " Stop arguing over WHO is going to pay for them and whether that should be public, private, third-party or other mumbo-jumbo.
Something is seriously wrong further back in the picture, further upstream, that should be on the table here if we want to "reduce costs" and "improve health" and maintain a healthy workforce for corporations to draw on for workers or for the military to draw on for soldiers, or for any of us to select from when looking for a healthy mate.
This approach of going back further upstream for solutions has worked well in the past. Rather than treating so many people with Cholera, we invested in making sanitary sewers and clean water supplies. Much better.
Rather than developing clinics that could replace a lung in under 30 minutes for under $100,000, we removed smoking cigarettes from the American mainstream. Much better solution.
Today, we have similar problems with cancer, diabetes, obesity, need for coronary bypass surgery, etc. Stop getting "better" at "solutions" that simply institutionalize the problem, and go back to solve the original problem. The best amount to spend on treatment is ZERO. Why do we have so many people who need coronary bypass surgery at all so that this becomes a matter of national policy debate? Something is seriously wrong further upstream.
Small and large business owners have missed their strongest leverage point when they focus on the question of WHO is going to pay for all the expensive treatment of their sick employees instead of on WHY are all these people getting sick in the first place?
It is not natural that so many people should be obese and diabetic, for example. We should stop arguing about who will pay for this and spend a lot more energy on the question - why is this suddenly happening?
This whole debate over "health care" is meaningless unless we stop talking about who pays and start talking about why so many people need so many repairs in the first place.
It's not a "given" that people just "are" that sick. In countries with better health care systems than the USA, people in general never even need these repairs in the first place, because they don't break.
Roger Cohen, today's New York Times, in The Public Imperative today says in part
A reader, John Dowd, sent me this comment: “In Europe generally the populace in the various countries feels enough sense of social connectedness to enforce a social contract that benefits all, albeit at a fairly high cost. In America it is not like that. There is endless worry that one’s neighbor may be getting more than his or her “fair” share.”
Post-heroic European societies, having paid in blood for violent political movements born of inequality and class struggle, see greater risk in unfettered individualism than in social solidarity. Americans, born in revolt against Europe and so ever defining themselves against the old Continent’s models, mythologize their rugged (always rugged) individualism as the bulwark against initiative-sapping entitlements. We’re not talking about health here. We’re talking about national narratives and mythologies — as well as money. These are things not much susceptible to logic. But in matters of life and death, mythology must cede to reality, profit to wellbeing.
I can see the conservative argument that welfare undermines the work ethic and dampens moral fiber. Provide sufficient unemployment benefits and people will opt to chill rather than labor. But it’s preposterous to extend this argument to health care. Guaranteeing health coverage doesn’t incentivize anybody to get meningitis.
Don't get me started on noting that the debate about "health care" in the US seems to have nothing to do with health, or even with care, but with some prostituted meaning of the term that has to do with which insurance middle-man company will profit from people's medical treatment, and who ultimately ends up paying for whose far-too-expensive treatments. It is an argument about money, not a discussion of what comprises health and what set of interventions in a person's life supports health.
So, let me at least make what seems an obvious point, yet one that is completely absent from this discussion in the national media. It is far cheaper to change the oil in your car than it is to replace the engine. Isn't this fact obvious to people?
It is cheaper, by a factor of about 100, to provide "primary care" (think "oil change") to people than it is to try to provide heroic repairs (engine replacements) after they have become seriously ill.
It is also CLEARLY to everyone's benefit that ANYONE who shows signs of infectious disease get some kind of treatment early, rather than continue to walk around infecting other people.
It is incomprehensible to me why one option of the public debate is not an insistence that EVERY PERSON in the country, legal or not, should receive primary health care (oil changes). This is not an entitlement to an open-ended credit card for expensive drugs and surgery -- it is a practical provision of expertise and advise and a little bit of medicine to keep the population from becoming sick and becoming an expensive burden.
Health is contagious. So is ill-health and many diseases. In fact, healthy life styles are contagious, and so are unhealthy life-styles. The reality is that, if we surround ourselves with sick people, we really increase the odds that we will become sick ourselves.
Almost all the increases in life-span in the last 100 years have come from public health, not from expensive hospital care. They have included such items as providing clean, safe, drinkable water, and requiring that restaurants and food-handlers follow rules that reduce the odds of massive food-poisoning episodes. These are provided on a social basis, to everyone, and make no sense to provide these to a few people and not to others.
It is in everyone's interest that everyone be able to go somewhere and get an education medical evaluation of why they do not feel well and what steps they might take to fix that. This does not require that we agree to pay $450,000 for open heart surgery for them. It is much more likely that the assessment will show that the person eats too much high-fructose-corn-syrup and needs to exercise more. Most of the ill health in the USA today is due to poor life-style choices, not germs.
It is not easy for a single human being to live a healthy life-style when surrounded by friends and coworkers who live unhealthy life styles. It's hard to quit smoking when everyone around you continues to smoke and offer you cigarettes every time you meet. It is easy to resolve that "I will exercise more" but it is hard to carry through with this, especially alone.
What can really help everyone be stronger is to live within a culture where the correct desired behavior, the one our bodies need and expect, such as exercise, is part of the cultural norm. If everyone exercises, and the world is set up to make that easy, it is far more likely that I will exercise too. There is a very strong "go with the flow" lemming-type effect here. People need that.
If it is very hard, on the other hand, and expensive, to go see someone at the first signs of illness, the odds that this will happen, let alone become standard practice, head towards zero. We will not go see the doctor for primary care if a doctor's appointment takes 2 weeks to schedule, or longer, and costs $100, and requires taking the day off from work and an insane wait of four to eight hours, with kids in tow, sitting in an "urgent care" center with 15 other people who clearly ARE sick.
The debate over "health care" in the US would do well to be subdivided into two parts -- one part dealing with the wretched stated of "basic family and primary health care" and the other part dealing with the far more expensive open-ended part of health care.
For example, why have we let the legal and financial system make it essentially impossible to have a first-layer of health care for people that consists of nurses and others who can deal with inexpensive situations in an inexpensive and very rapid way, including advice over the telephone? Yes, such a system will miss some subtle issues that expensive MD's would have caught; on the other hand, it will just as definitely CATCH many situations that MD's would have missed, particularly if the lower-paid staff can develop a more frequent contact with the patient, learn their names, become familiar with their family situation, and understand at a glance what's up with Sid today, again.
There are a very limited set of things that expensive MD's, in expensive offices, can detect in a 12 minute appointment where the doctor must spend 7 minutes typing on their computer during the "visit", and every visit you see a different doctor who doesn't even know your name. That system, is, in fact, BROKEN AND DEFECTIVE. It makes no logical sense in terms of actual physical health care, only in terms of the logistics of setting up a chain of "visits" that are easy to record and bill for the "health care system".
In other words, the actions, buildings, equipment, and personnel in our doctor's offices and hospitals are essentially working all day to support the health care system itself.Treatment, and actual improvement in the health of the patient has become a secondary objective, often forgotten and lost in the mix.
Meanwhile, as is obvious walking through any crowded space, elevator, station, or office in the late autumn, many people are busy coughing and sneezing and barely remaining upright, because they didn't have primary care, let alone a social environment of care in which, when they are sick, they can actually stay home and rest as they should. We accept it as "normal" that people who have "exhausted their sick days" (if they ever had any) will simply come to work sick and infect the rest of us.
The whole method of dealing with primary care is broken. That's a totally different problem than who is going to pay for elective heart surgery for Mr. Jones.
1 comment:
Yes!
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