Physician, Heal Thyself

For years, I've been saying that the problem with health care in America lies in its self-definition: health care industry. I've never really been able to articulate the particulars of it. I don't think I could even now; it was something I just knew. The closest I got was pointing out an example from my childhood of why Walter Reed, a not-for-profit hospital, was a world-class medical facility.

My stepmother hurt her ankle at a youngish age and it never fully recovered. It was normal and functional in all respects, just very prone to spraining, pulling; it went out a lot, etc. My father was active-duty military when they married, so she got full medical benefits. One of the first things they did after the honeymoon was to have her ankle examined at Walter Reed. The doctors there were able to do what so many others before could not: they operated on her ankle and eliminated the problem.

I know...I know...anecdotes prove little and a single anecdote even less. But thanks to the internets, we have people far more eloquent than I who can put these things in real terms. As in this piece, where we are introduced to Critical Condition: How Health Care in America became Big Business and Bad Medicine, by Donald Barlett and James B. Steele:

If you want an example of something that's emblematic of what's broken in America, try health care.

...for twenty five years the United States, under Republican leadership and the hand of big business, has indulged in an experiment with allowing "market forces" to drive our health care system.

That experiment has failed.

We pay more for drugs, basic care, and insurance than ever before.

Barlett and Steele:

Over the last few decades, American health care has radically changed. A system that was largely not-for-profit has become a field where the profit motive and market forces affect every decision.

...Much of the turmoil is a direct result of a national policy to run health care like a business, a misguided notion promoted by Washington over the last two decades that the free market and for-profit health care would restrain costs and bring high-quality care to all. On both counts, the experiment has failed miserably. In the meantime, tens of billions of dollars--money that could have gone into patient care--has been drained from consumers and corporate subscribers and transferred to investors, executives, and others who have a stake in perpetuating this myth.

The result is a chaotic system that has shifted its focus from saving lives to saving dollars, one that discourages preventive medicine and rewards overtesting and overmedicating; a system that allows insurers to reject those most likely to require medical attention and keep only the healthiest; a system where six times as many people die from medical mistakes as from HIV/AIDS; a system that forces doctors to spend as much time negotiating with insurers over referrals and fees as they do treating patients.

...Health care isn't like other "businesses" where it's perfectly acceptable to make more money by selling more of your product. When talking about our health, that's insane. We want fewer diabetics and lung cancer patients...As a society, we want our citizens to be healthy, to need less, not more, intervention from the health care system. That was the logic behind the initial governmental investment in "non profit" HMO's in the 1970s.

It is sound logic indeed: non-profits have an incentive to keep costs down. In health care, this translates to an emphasis on prevention, with the goal of reducing the need for medical care. To free market idealogues, however, it is anathema.

Barlett and Steele:

In 1983 alone, five formerly not-for-profit HMO's with hundreds of thousands of enrollees converted to publicly owned corporations.

...The move to for-profit health care companies was a profound transformation that would affect milllions of Americans. It was rationalized, explained, and justified for one reason--as the only way to control costs. "The object will be to slow the explosive rise in the nation's medical bill." Business Week reported, "and set in motion free market forces that will reduce the waste, inefficiencies, and misuse of health services that have eluded the corrective thrust of government regulations." For-profit HMOs were the "Johnny-on-the-spot answer to the health care cost problem," said a Piper, Jaffray and Hopwood analyst in 1984.

...At the time, in 1984, health care costs represented 10.5 percent of gross domestic product. Twenty years into the experiment to "slow the explosive rise in the nation's medical bill," health care costs at the end of 2003 exceeded 15 percent of GDP. They are sill rising. The last time so many on Wall Street and in government were so wrong was 1929--but this time many would make a great deal of money.

And there you have it: there is no money to be made in keeping people healthy, only in treating their medical problems. Prevention is eschewed for prescriptions. Take the subject of nutrition, for example. Dietary habits have a direct and often profound effect on one's overall health. The critical importance of nutrition is not a subject of debate and yet the subject is not routinely addressed in medical school curricula. You can see for yourself; schools offering coursework in nutrition are the exception, not the norm. It's quite a staggering omission, given the integral role diet plays in our well being.

I know that when I was in medical school, nutrition education consisted of little more than a passing reference here and there. Unfortunately, even though our understanding of the relationship between diet and health has grown exponentially, medical training generally has not caught up with current understanding.

A recent study graphically demonstrates the troubled state of nutrition education in our nation’s medical schools. As reported in the December 1997, issue of Harper’s, 74 percent of first-year medical students “believe a knowledge of nutrition is important to their career.” By the time students are in their third year, though, only 13 percent feel that way.

The fact remains that diet is one of the most significant determinants of health and is the factor over which most patients can exercise nearly complete control. Given the scant attention most doctors give to nutrition, it is no wonder that heart disease, stroke, adult-onset diabetes, hypertension, various cancers, and many other diet-related disorders present at such overwhelming rates.

I suppose it's somehow fitting that the "land of plenty" should have the highest obesity rates in the world. According to the National Health Policy Forum, obesity in America is already characterized as "epidemic" and shows few signs of abatement.

In the United States, obesity is an increasingly problematic public health concern. The prevalence of obesity among U.S. adults has increased dramatically in recent years. In 1991, only 12 percent of adults were obese. By 2001, almost 21 percent of adults were obese, representing a nearly 75 percent increase.

...Even more alarming is the increase of those who are morbidly obese; that is, those who are 100 pounds or more overweight. According to Roland Sturm, a Rand economist, about one in 80 men weighs more than 300 pounds, a 50 percent rise from 1996 to 2000, and one in 200 women weighs more than 300 pounds, representing a 67 percent increase.

With few exceptional scenarios, obesity is an entirely preventable condition. Which means many of its resultant health problems are largely preventable. But there just isn't any money in telling people to eat their broccoli.