Wednesday, October 14, 2009

Diagnosis: Celiac (Part 2 - The Slippery Slope of Solutions)

It's one thing to criticize the health care system as being badly broken, but quite another to criticize it AND offer a suggestion for a viable solution. And yet, solutions are what is needed. You could look to yesterday's post for a reason why we need solutions. Or you could let statistics speak for themselves:

When the World Health Organization unveiled its World Health Rankings in 2000, the U.S. came in 37th, behind countries such as Costa Rica, Morocco, and Colombia. Admittedly, the task of ranking the world's health systems has become an incredibly complex one, and it is a process that has been criticized of having bias inherent in the formulas used to calculate the rankings. For that reason, the WHO has ceased publishing official rankings. But the WHO does continue to publish health statistics, which are free of bias, and which - I think - are even more telling (and more damning of the U.S. health care system) than the 2000 rankings.

I did a query of the WHO database, comparing the United States to other developed, Western countries such as Canada, Australia, Ireland, United Kingdom, Belgium, Norway, Germany, France, Switzerland, Spain and Portugal. And I looked at data for those countries that couldn't lie: adult mortality rate, infant mortality rate, life expectancy, healthy life expectancy, rate of obesity. The U.S. rated last in every statistic. We have the highest adult mortality rate, the lowest life expectancy and the lowest healthy life expectancy. Our infant mortality rate is the highest, too, roughly double that of many other countries in the comparison. And our obesity rate far exceeds any other country (we're nearly four times that of Italy, and more than five times that of Norway).

So even momentarily setting aside the issue of Celiac Disease, the health care system in our country is not working. Then we bring Celiac and its nuances back into the picture, and we have a heightened personal stake in the issue, coupled with a pretty compelling mandate for change.

But what would change look like? What would be an effective solution? On the surface, the solution seems obvious enough: ensure that all Americans have basic, essential health coverage (irrespective of age, race, gender, religion, sexuality, pre-existing conditions, etc.). But then the slippery slope comes into play...

First, should all Americans pay the same to be part of such a solution, or should some Americans pay more than others on the basis of pre-existing conditions, risk factors, and other considerations. The latter is already happening to a large degree. People with pre-existing conditions are paying more to join health insurance plans, or are being directed to individual and group plans that have inherently higher rates to cover the anticipated added medical expenses associated with caring for those individuals. We're also seeing an expanded role of "lifestyle taxes." There's the sin tax on tobacco and alcohol. There's a new debate about a possible sugar tax. And another new debate about a possible so-called fat tax (both charging obese people more to obtain health insurance, AND levying a tax of fattening foods).

On the one hand, it seems only sensible to pro-rate costs. Not all individuals will utilize the health care system equally. But on the other hand, deciding how much to pro-rate costs according to each person's unique profile is a near-impossible task (how do you weigh family history and genetics against environmental risk factors against personal lifestyle choices? how do you measure the risks of the cautious mountain climber against the careless driver who's texting?). Not to mention that pro-rating walks a very fine line that could easily tip over into discrimination. (And I can think of a hundred other examples where this slippery slope leads into murky waters, such as a sin tax on alcohol - too much alcohol is bad for you, but moderate consumption is actually good for you... so do we need a combined virtue payment and sin tax, depending on whether you drink a glass a day or a bottle a day? But I digress...)

Second, there's the seemingly obvious statement of providing "basic, essential health care" to all Americans. Well, what constitutes basic, essential health care? Making such a determination immediately sets us on a course of having to make value statements and tough decisions. Is a procedure essential or not? If a procedure is deemed elective, are all elective procedures voluntary? Or should some be deemed medically necessary? Again, we're walking down a path of subjectivity, which opens itself up to criticism.

Third, there's an issue of restructuring the payment system. Denver's 5280 magazine recently published an interview with an area doctor who made an interesting point - at present, doctors get paid by the insurance companies in part for ordering tests and procedures. To this degree, docs are incentivized to order more tests and procedures, which is not the same thing as helping a patient to get healthy. Instead, this doctor proposed an alternative in which doctors get paid for performance... in essence, they get paid for succeeding in helping patients to be healthy.

At first glance, it seems like a no brainer. I think such an approach would go a long way toward shifting our health care system away from sick care (which is what it really should be called) and wellness care (which is what we're striving for). But then that slippery slope creeps in again. If we financially reward doctors for the health of their patients, then what would stop them from skewing their patient loads toward healthy people and excluding unhealthy patients, in order to maximize the performance incentive? We'd need to regulate doctors the same way we're now trying to regulate insurance companies on the issue of excluding patients from insurance plans because of pre-existing conditions. Then there's the issue of exactly how we'd measure "healthy patients." Take their blood pressure? Cholesterol? Predict their lifespan? Ask them how happy they are? I have no idea...

The real struggle, I think, is that all parties involved - the patient, the health care provider, the health insurance company, and the government - need to have a stake in our well-being. Only then can they begin to make decisions that are in the best interest of the person. Allow me to share my landlord-tenant analogy to explain. I used this analogy a lot when talking about the environment, and energy conservation in particular, in my pre-writer days when I worked for an environmental non-profit. If a landlord includes all utilities in a renter's lease, the renter has no financial incentive to conserve energy, because they don't pay those costs. They crank the AC in the summer, and turn up the heat in the winter (maybe enough so that they then open a window to cool down an apartment!). They leave lights on, and electronics running. Conversely, if the renter pays all utilities, the landlord has no incentive to install energy efficient upgrades - better lightbulbs, better appliances, improved insulation, better windows. Only when landlord and tenant share the cost of utilities do both parties have an incentive to conserve.

I think a viable solution to the health care dilemma might take a similar approach. If all parties had a financial stake in promoting a healthy individual, they'd all take steps to make that happen. And if the patient's portion of the financial pie was some percentage of overall costs, they'd be financially motivated to make healthier choices, because their expenses would scale up or down with their medical costs. They'd be financially motivated to lose weight. Eat better food. To make the kind of lifestyle decisions that would decrease their medical expenses. And we wouldn't need sugar taxes and fat taxes and sin taxes to do it. (I'd like to think that our own health would be enough of an incentive, but that's clearly not enough to get Americans to make better choices based on the statistics and trends...) Of course, even that proposed scenario has its own challenges. Most notably, ensuring that a patient's share of the financial pie doesn't become a huge financial burden they're unable to pay. Somehow, a solution needs to remain affordable. Sigh...

What's more, I think we need a combination of regulation AND incentives. This perspective I also gleaned from my environmental days. We need regulation to set boundaries, to establish acceptable operating parameters. But we also need incentives to help push things further in a desirable direction. (For justification of this position, I think we could argue pretty strongly that given the current state of affairs, financial incentive alone hasn't worked...given the failure of a purely privatized, capitalist approach to health insurance that relies upon Adam Smith's Invisible Hand to guide us.)

In the end, I think it's important for all stakeholders to remember that life is a pre-existing condition. What I mean by that is that we all face risk factors. We're all going to be sick at some point in our lives. Sure, the details will differ from person to person. But inevitably, we'll all be in a similar boat at one point or another. Some of the factors are in our control. Some are not. But we all need health coverage, regardless of the nitty gritty details.

One of the justifications insurance companies have cited for keeping Celiacs in the "excluded due to pre-existing condition" category is that such patients can't be measured in their "compliance" with a gluten-free diet. This really irks me. In my experience, people with Celiac are actually some of the most likely patients to adhere to a diet prescribed by their doctor! This is no doubt due to the fact that we can almost immediately and very clearly see the improvement in our health, and we immediately feel the effects of a gluten contamination. We are fiercely incentivized to stay true to the diet. Compare this to, say, the person with high blood pressure or high cholesterol, and whose doctor tells them they need to shape up. How many don't follow those doctor's orders? Maybe that's because the blood pressure and cholesterol don't provide the kind of immediate feedback that gluten does to someone with Celiac, and the effects are longer-term, finally showing up years later as a heart attack, maybe.

My point, again, is that life is a pre-existing condition. There are a million tiny factors that influence each person's health profile. And it seems unfair to deny coverage to certain people with pre-existing conditions, while millions of other people may be just as burdened by health issues. Which brings me back to the beginning. We need basic, essential and affordable health care for all Americans. That much I know. What remains to be seen is how that can be achieved in light of the slippery slope of solutions.

Coming tomorrow: Part 3 - The Case Study. I've spent two days talking about ideas and hypotheticals and anecdotal stories. That's all well and good (and lengthy...looking how much I've been writing). But I decided to dive head first into the issue by using myself as a guinea pig and wearing my investigative journalist hat. I approached four health insurance companies with a scenario, and you'll be surprised to see how complicated the responses quickly got... This specific example will go a long way toward illustrating how someone with Celiac Disease can navigate the health insurance quagmire today, and hopefully how we can advocate for better health care reform tomorrow.

- Pete


Anonymous said...

Health Insurance needs some fixing. However, people need to take responsibility for their health by eating healthy foods, and maintaining a healthy lifestyle. With that said, our health care system cannot be "fixed" overnight as it seems to be going that way. If your house needs repair, you don't tear down the whole house and rebuild it. Fix the things that are broken. Also, take your time and make an action plan. It takes time and meeting of the minds of many people in respective fields. Not 8 months.

peterbronski said...

Hi Anonymous... I absolutely agree that people need to take responsibility for their health by eating well and maintaining a healthy lifestyle. Tackling the standard American diet and obesity/lack of exercise would certainly do good things.

However, I do disagree with several of your general comments.

Our healthcare system is not being "fixed" overnight. Meaningful healthcare reform has been in the works for nearly a century. Many presidents have tried, and yet all have sadly failed (reform attempts have repeatedly stalled in Congress). There was Roosevelt in the 1910s, FDR in 30s, Truman in the 40s, Kennedy in the 60s, Nixon and Carter in the 70s, and Clinton in the 90s. We don't have the luxury of time to sit on the issue while millions of Americans are without health insurance.

Re: your house analogy. Sometimes you fix a problem, but sometimes you also have to declare a situation a "total loss." In such a case, the best course of action is to rebuild from scratch. To use your house analogy, if you have water damage, you can replace the sheetrock and apply new paint, but if you don't fix the leak, the problem will return. To put it another way, what is the point in making superficial adjustments and "fixes" if there's a greater, fundamental, underlying problem that should be addressed? This has been the problem with health care reform. Over the course of the same century that presidents have been trying to tackle the issue, congress has been applying well-intentioned and sometimes effective band-aids that have done too little to contain the real problem (Medicare, Medicaid, COBRA, etc.).

The health care reform debate has dragged on for too long, and we've been stuck in the rut of the status quo. It's time for less talk, and more action.

Cheers, Pete