Wednesday, June 24, 2009
There are two schools of thought on this nation’s health care dilemma. One asserts that the primary issue is the 47 million uninsured. It holds that were all Americans covered under a single-payer system, the greater part of the problem would be well on the way to a solution. The other asserts that the uninsured are but a symptom of a far more critical underlying problem. That pathology is the cost of health care. Were it not for that exorbitant cost, health insurance would be affordable to virtually all, and fair value would be received for the premiums paid.
While the proposed Republican solutions for health care, by and large, will be ineffective and are off point, they are on point in identifying the crux of the problem. The core issue is cost, not coverage.
The expenditures are massive. Health care spending in the U.S. now exceeds $2.2 trillion annually ($7,420 per person), more than 16 % of the GDP (gross domestic product). The Congressional Budget Office predicts that by the year 2025, the U.S. will be spending 25% of its GDP on health care. In 1960, it was only 4.7% of the GDP. The cost of health care is devouring our economy.
It would be a relatively simple issue if we, as a society, were paying for these expenditures out of our past wealth or our present income. We are not. We are financing our current health care through the burdening of the next generation. If one includes Medicare and Social Security obligations, the federal government’s unfunded liabilities are $455,000 per U.S. household. Expenditures on health care in the U.S. far exceed the means of a nation with a declining industrial base.
From the left, the talking points are “single payer” and “universal health insurance.” From the right, it is “health savings accounts.” All are off the mark; they are largely irrelevant in slowing the rise in health care expenditures.
Some “expert”, somewhere, in each party, must realize that their “solutions” are fundamentally incapable of containing the accelerating expansion of the nation’s health-care budget. Yet, they are silent.
Another widespread criticism of American medicine is that it is “based on treating illness, and not on promoting wellness.” Treating illnesses, of course, promotes wellness, but what the critics really are saying is that if our nation’s priority were on preventive medicine, much, if not most, of those illnesses would no longer be present, and the treatments would therefore be unnecessary. This is nonsense, but it is a philosophy pervasive throughout much of academia and the media. There are significant benefits, of course, that can be realized. Early detection of asymptomatic disease is certainly valuable. But cholesterol screening, blood pressure measurements, colonoscopies, pap smears, mammograms, etc., are standard medical practice and their savings already are built into the system. Moreover, the impact of some of these interventions is less than commonly realized. For instance, women who have mammograms every one to two years have a 16% to 19% lower death rate from breast cancer. That’s an impressive figure; but clearly, even if every woman in the country had yearly mammograms, the great majority of breast cancer deaths still would not be prevented. Regardless, in financial terms, even if penetration of the above interventions were to encompass 100% of the population, the savings would be modest at best.
The other arm of preventive medicine, beyond that of screening, is lifestyle modification, such as good nutrition, supplements and healthy living.
Science shows that a healthy lifestyle can extend one’s lifespan by nearly a decade. But short of prohibiting alcohol, banning tobacco and taxing red meat etc., we have likely reached the public health limits of the benefits of lifestyle modification. The current mandate, compelling doctors to document lifestyle education into the medical record, is largely an exercise in futility. And for what its worth, chronic disease generally is not prevented by lifestyle modification; it is delayed. The two (prevention and delay) are not synonymous. The diseases, and the expenses, arrive approximately ten years later.
The “prevention” position further claims that “doctors (profit) from repeat visits. There is no financial incentive to keep patients healthy.” That statement refers to the fee-for-service model, as opposed to pre-paid health plans, and implies that for financial reasons doctors, as a rule, let their patients become sick. There certainly are corrupt doctors, but those who would keep their patients sick for profit are few and far between. The purely mercenary tend to go to Wall Street, not medical school.
The positions we take run contrary to the prevailing conventional wisdom. Among the topics to which we give a fresh perspective are medical education, malpractice and defensive medicine, the insurance industry and managed care, the pharmaceutical industry, single-payer systems (Medicare and Medicaid, the Veterans Administration, the Canadian health plan), lobbying and mandates.
We propose the following.
The current medico-legal system must be entirely revamped. Both patients and physicians must be protected and victims of malpractice compensated. Insurance companies must pay for services ordered or performed by any physician that is a "provider" for that insurance company. Only catastrophic or major illness insurance should be required by all. This should be private, not government run. Allow individuals to buy insurance through affinity groups. Direct to consumer marketing by drug companies must be banned. Government mandates should be abolished.
Government should help those in need through vouchers. Medical education must be totally revamped, eliminating several unnecessary college years. Tuition should be minimal; in return, physicians will be required to work in undeserved communities or community health care centers for 2 to 3 years. Utilization of non physicians for simple primary care, such as pap smears, BP check, cholesterol screening, and health checks.
We explain these proposals and more, at
Peter Weiss M.D., F.A.C.O.G. is Director and Founder of The Rodeo Drive Women's Health Center and the Rodeo Drive Health and Wellness Centers. He is Assisstant Clinical Professor of OB/GYN at the David Geffen School of Medicine at UCLA
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