HealthCommentary

Exploring Human Potential

Post-Charlottesville – We Need Caring Health Professionals More Than Ever!

Posted on | August 17, 2017 | No Comments

Source: Jason Lappa, NYT

Mike Magee

Collectively health professionals have a unique role in American society. Across cities and counties, rural and urban, we are asked to be available and accessible to help keep people well and respond when they are sick or injured. Those wounds come in all shapes and sizes – wounds to the body, wounds to the mind, wounds to the spirit. As important as are our diagnostic and therapeutic interventions to society, they pale in comparison to a larger, often over-looked function. Together, collectively, we process day to day, hour to hour, the fears and worries of our people, and in performing this function, create a more stable, more secure, more accepting and more loving nation.

With Charlottesville etched in the American psyche, good-willed Americans are in search of our true center. As a physician, I recall patients whose goodness and courage and kindness brought out the best in me and my colleagues. That after all is the true privilege and reward for doctors and nurses and all health professionals – the right to care.

Nearly six years ago, my wife and I were blessed with the arrival of our eighth and ninth grandchildren – two little girls, Charlotte and Luca. We were also introduced, for the first time as health consumers, to the Neonatal Intensive Care Unit (NICU). The girls came early, at 34 weeks, and struggled to work their way back up to their due date. They are doing great today, but in those early days, it wasn’t easy on them or their parents or the care teams committed to their well being.

Viewing them from my grandparent perch, the Connecticut Children’s Hospital Center NICU team at Hartford Hospital did a great job, balancing high tech with high touch, providing wisdom and reassurance, inclusion and training to the girls’ parents, who were inclusively inducted as part of the team on day one. Viewing it all from my vantage point as a former surgeon, hospital administrator and health policy analyst, I was impressed, but not surprised.

When people claim that “America has the best health care,” they’re usually referencing groups of highly skilled doctors and nurses and other caring professionals, committed to their patients and to each other, armed with experience, judgment and technology to – collectively – heal and provide health, and keep us whole in the process. It’s really a holy thing to observe.

What that NICU experience illustrates is that we health professionals are fully capable of collaborative and humanistic care, especially when faced with a complex crisis. But the challenge today, in the face of purposeful Presidential segregation of our citizenry, is to extend the same blend of knowledge, skill, compassion and partnership to all patients on a day-to-day basis. How do we assist them in creating healthy homes, healthy families and healthy communities?

If you deconstruct the success factors embedded in our NICU experience, what do you find, independent of the scientific skills, sophisticated technology and ultra-focus on the patient?

There are three elements that are worthy of note.

1. Inclusion: For most humans, the first instinct when faced with trauma or threat is flight. And yet, these NICU professionals’ first instinct was inclusion. With IVs running, and still groggy from her C-section, our daughter and her husband were wheeled to the NICU and introduced to their 3 lb. daughters. They were shown how to wash their hands carefully, how to hold the babies safely and without fear, and – while given no guarantees – experienced the transfer of confidence from the loving and capable caring professionals to them. Those were remarkable first day gifts to this young couple.

2. Knowledge: Coincident with the compassionate introduction to their daughters, there was a seamless transfer of information – each of their daughter’s current conditions, an explanation of the machines and their purposes, the potential threats that were being actively managed, and the likely chance of an excellent outcome. This knowledge – clear, concise, unvarnished, understandable – delivered softly, calmly, and compassionately, reinforced these young and fearful parents’ confidence and trust in each other, and in their care team, on whose performance their newborn daughters’ lives now depended.

3. Accessibility: Clearly a NICU is a 24/7 operation. But that alone did not assure that the needs of these patients and their family would be met. First, members of their care team needed to demonstrate “presence.” By this I mean, by communication, touch, voice, and face, they needed to connect to the parents, to signal that they cared for these unique individuals. The outreach needed to be “personal.” This was not a rote exercise for them, not just another set of parents, not just another set of tiny babies. These were these specific parents’ precious children, their lives, their futures were now in the balance. And the performance needed to be “professional.” The team needed to be consistent and collaborative, with systems and processes in place, no descent and little variability in performance, rapid response, anticipatory diagnostics and confident timely management of issues as they arose.

As we recover as a nation from Charlottesville and Trump’s self-inflicted wounds, we caring health professionals need to mirror a better way – holistic and inclusive, humanistic and scientific, where goodness and fairness reside side-by-side. How might each of us actively demonstrate a commitment to inclusion, knowledge transfer and accessibility, and in doing so, assure that our patients respond with confidence and trust in America?

“Let’s Make America Healthy Again!”

Posted on | August 8, 2017 | No Comments

Source: SSRS

Mike Magee

As the Democrats continue to angst over messaging and a platform to appeal to America’s middle class, the answer is staring them right in the face. A poll this week by SSRS made it abundantly clear. But before I go into that, let me provide a winning banner for the 2018 election: “Let’s Make America Healthy Again!”

The opinion polling on Trump above shows clearly that the President’s approval has broadly eroded over the past 200 days across the board. But nowhere is this more evident and more conclusive than in health care policy where 62% disapprove and only 31% remain in the Trumpcare corner. As interesting, but not surprising is the close runner-up and mirror for disapproval – “helping the middle-class”.

The economic case for moving progressively  toward a universal, centrally administered/locally delivered system of health care has already been made by Warren Buffett and others. The potential savings are indisputable, and the gains in worker productivity, mobility, and family security could be transformational.

But if you were a governor of a state, let’s say like Ohio, how might you approach answering the question “How do I make Ohio healthy again?” Your first instinct might be to reactively throw all your resources at the raging opioid epidemic, but that would ignore a wide range of other priorities and opportunities.

You might take a moment to consider what you mean by health in the broadest terms rather than health care. If you were a seasoned leader, with strong ties to your community and public service flowing through your veins, you likely would conclude that health is an active state of wellbeing that encompasses mind, body and spirit. It is the capacity to reach one’s full human potential, and, on a larger scale, your own state’s potential for development.

As a governor, you might take the time to read the latest National Academy of Medicine publication “Building Sustainable Financing Structures for Population Health: Insights from Non-Health Sectors”, and highlight in yellow: “Health is often a side benefit of policy programs in other sectors”.

You would certainly want to take a moment to absorb one expert voice’s plea that “Many of the challenges that people face in the area of economic development and in realizing individual potential are health-related issues. For example, health care can be an invisible barrier to success in school performance.”

Having spent so much time in town meetings and walking the neighborhoods of your state, the words of another contributor would have to resonate: “The context in which people live affects health. There are numerous social determinants of health within one’s neighborhood – concentrated poverty, crime, walkable neighborhoods, the ability to exercise, access to healthy food.”

You would take a moment to reflect on the insight that the benfits of investments in the social determinants of health may not immediately ease a parent’s struggle but will change the trajectory of their children.  “Have I considered  a long enough horizon?”, you might ask yourself.

That horizon is effected not simply by the learning environment, nutrition and safety, but also by the physical environment. As the report declares, enlightened leaders “understand that everything they breathe at home and everything that comes through their pipes matters to their health.”

Finally, you would likely see in health, a broader call to action in the report’s words: “It is important to take a holistic look and realize that when making environmental changes, school changes, or economic changes, the capacity of the people in those communities must also be increased. They need to have or develop the agency, the voice, the leadership, and the capacity to govern their lives and become self-sufficient at a higher level because they are now living and working and trying to succeed in a new environment.”

Highlighting those final words, the governor – Republican or Democrat – might suddenly realize, “This is it – the unifying theme I’ve been searching for.” And standing to engage the next round of leaders who have just arrived at your state house doors, you might be overheard silently mumbling to yourself, “Let’s make America healthy again. I like the ring of that.”

The Winning Argument For Universal Health Care Is Economic Not Ethical.

Posted on | August 3, 2017 | 2 Comments

 

(Check out your state HERE)

Mike Magee

The optimistic top line headlines today dominated health news even while Congress struggles on the very basics of health delivery. “U.S. scientists fix disease genes in human embyos for the first time”  blares USA Today. But turn to the Opinion page and you’ll find “Trump admits that sabotage is real Republican health care plan.”

What these competing headlines make clear once again is that scientific progress is not synonymous with human progress. Our faith in free enterprise and capitalism to “win the war” on disease (and supposedly leave “health” in its wake) dates back to the immediate post – WWII era. Over the years we’ve doubled down on this historically poor decision again and again, breeding profiteers, colluders, and promoters – but not much health for America.

The historic intermingling of health and business has yielded a long list of side-effects including: academic medicine’s rush for NIH grants, sellable patents, DTC advertising and AMA profiteering database sales, industry’s relentless assault on checks and balances and their expanding government relations, and government’s open door policy toward scientists with well known conflicts of interest. All spell success for the ever expanding Medical-Industrial Complex, but treat patients as pawns.

The cast of characters and drama that is unfolding resembles the Soviet Union’s demise on December 26, 1991. For a solid decade preceding this event, the power elite of that federation vigorously defended their status quo and the reckless build up of their military spending which eventually sent them over the financial cliff. Our misdirection of American healthcare is heading rapidly toward a similar endpoint.

The winning argument for a restructuring of our healthcare system and the movement toward single payers is economic not ethical. Universal coverage is necessary not because it’s a human right (which it is), but because risk must be shared to make insurance work, and uncovered citizens ultimately cost society more – much more! A healthy population is more productive, more likely to be educated, more mobile and willing to take risk, more likely to get married and have children, less likely to be involved in crime, violence, or injury. And all of this saves money.

When Warren Buffett said that “Medical costs are the tapeworm of American economic competitiveness”, he knew what he was talking about. But to responsibly transition ourselves out of this mess requires two things: 1) a vision/strategic plan, 2) the capacity to retrain and redirect health care workers from reactive health delivery to proactive and preventive social services.

On the vision front, studies clearly indicate that consolidating administrative back-office management of insurance sales, benefit management, and claims payments could immediately shave 15% off our national health care bill. But getting there is not as easy as uttering the magic phrase, “Medicare-for-all”. Let’s remind ourselves that while Medicare is quite efficient compared to private insurers, it is not a single-payer system. One third of Medicare enrollees voluntarily participate in Medicare Advantage plans run by private companies who receive special incentives and subsidies out of our tax dollars. The good news is that the government attaches strings to the deal like enforced caps on out-of-pocket expenses. Also one fourth of enrollees have supplemental “Medigap” policies.

Seniors strongly support Medicare as it exists, as do many employees who receive insurance as a work benefit. So when we begin to think about moving to a single payer, we need to think about an incremental option that allows those who wish to switch versus brute force. A huge change like this will take time, and flexibility is our friend not our enemy. For example, Canada leaves the planning, prioritization and delivery of care in their “single-payer” system in the hands of the separate provincial governments. This is not dissiliar to the way we expanded Medicaid, providing baseline standards and financial subsidies from the federal government but giving each governor the authority to balance and integrate local health delivery with a range of other social services. Having local control of both buckets may be essential in transitioning workers in the near future.

Workforce transition is at least as great a challenge as shared responsibility. For every one physician in America, there are 16 additional health care workers. Approximately half of them are non-clinicians uninvolved in hands-on care. And not all the clinicians actually care for patients either. Name brand doctors in big academic centers today, touting “personalized medicine” this and “personalized health” that often more closely resemble dot-com entrepreneurs than the hands-on caregivers making rounds and teaching house staff of years gone by.

Health care now includes 11% of all workers compared to 8% in 2000. Since the country’s near financial collapse in 2007, 35% of the job growth has been in health care, fueled by aging demographics and the expansion of Medicaid under the ACA. More than 1/2 of the nearly $4 trillion spent on health care in the U.S. goes to wages. You can find a list of some the jobs, along with average salary and educational requirements HERE. The American Academy of Professional Coders is now nearly 200,000 strong with average salary approaching $50,000 a year. Near 20% growth in healthcare jobs is projected by the government in the coming decade, adding an additional 2.3 million positions is we maintain the status quo.

Shifting toward universality, planning, prevention, and efficient management will be profoundly disruptive to many workers. The impact would vary from state to state depending on their historic over-weighting of the health care sector. For example, listed above are the top ten states (including D.C.) ranked by the highest number of health sector workers (excluding those self-employed) per million citizens. The D.C. outlier reflects the Medical-Industrial Complex’s commitment to self-interest lobbying. States like Massachusetts, Rhode Island and New York have large academic enterprises with active industry partners. States like North Dakota, Maine, New Hampshire and Vermont have small widespread rural populations many of whom are economically vulnerable.

The point is, adjustments of work force in response to substantitive health care reform would need to be addressed on the local level and would be a significant challenge to state governors.

A starting point would be to deconstruct enterprises which primarily service direct care needs from those engaged in speculative scientific discovery for profit. These are radically different entities. Step two would be to integrate direct patient care with the continuum of social services. Plan for health, not disease. Finally, be bold. If we want to avoid Russia’s fate, change must be our friend.

How Medicaid Is Socializing and Polularizing Single Payer Approaches To Population Health.

Posted on | July 25, 2017 | 2 Comments

 Mike Magee

As the Republican controlled Senate prepares for a ballot today to vote on a bill yet to be identified, their governor counterparts in 31 of our 50 states are fast at work familiarizing themselves and socializing themselves to a new way of managing the health of populations within their geographic boundaries – single payer systems.

Despite the attempt to brand the term “single payer” the way that Medicare was attacked a half century ago as big government “socialized medicine”, the majority of governors has tacitly acknowledged what Warren Buffett described as a health care status quo that is “the tapeworm of American economic competitiveness”. The decline of state economies reinforced by the burden of weak social systems, challenged and undermined by a raging opioid epidemic, have caused Republican governors like John Kasich to declare independence when it comes to health policy.

Way back in 1965, when Canada endorsed a single payer approach for all Canadians, Americans did the same – but only for those over 65. We called it Medicare, and while it has had issues over the past half century, Americans long ago decided they couldn’t live without it. Of course, until now, they also consented to widening income disparity and health inequality based on a system of “have’s” and “have-not’s” when it comes to the good fortune (or lack of the same) of possessing health insurance.

President Obama’s federal subsidization of an expanded Medicaid with broader eligibilty and more generous coverage and protections hit the sweet spot with all but the reddest of red state governors. Those hold-out’s were literally willing to financially cut off their noses to spite their faces. For others like Kasich who were willing to give President Obama a chance, they liked the way it felt to actually lead and so did the citizens in their communities.

Medicaid celebrated a new approach (within the corridors of defined eligibily) of universality, access, health planning, portability, and integration with other social service programming. Participating governors liked the fact that the program was well funded, that the benefit package was broad (not a sham like the HSA induced high deductible/ empty benefit products proliferating everywhere), and that they preserved the flexibility within bounds to set the priorities on spending and defined how best to advance the overall health of their state populations.

The governors learned that centralized administration of a universally available health insurance offering carried distinct cost savings. Specifically, governor guided single payer health delivery under Medicaid came in 22% less costly than privately insured comparators. Governors like Kasich were left to wonder what might be the economic impact on Buffett’s “tapeworm” were their lessons to be applied across our entire population – single payer back office administration combined with state controlled and planned integrated health delivery. They read the studies that showed a potential immediate 15% savings on our 4 trillion plus annual bill simply by consolidating management of a universal coverage approach in a central systematized fashion.

Governors also could see that the human resource implications of such a move. Our purposefully complex program, which now threatens to break the American economy in much the same manner as reckless military spending collapsed the Soviet Union, has spawned 16 non-clinical jobs in health care for every one clinical role. A shift to single payer, poorly planned and transitioned, could carry with it massive unemployment. But if you look at innovators like Kasich, what you see is active reassignment of jobs by skill in a manner that advances the public good. The governor well understands that the U.S. is the only civilized nation in the world where more is spent on the mechanics of disease fighting than on all social services combined – the very combination of services and supports that help keep a population well. With flexibility, as wildly expensive nursing home use declines, those employees, now mobile, are an immediately useful and experienced mobile home services health corps. Given room for innovation, as they have been under the ACA, governors have applied both innovation and structural remodeling to expand safety, security, and health across multi-generational families.

The Medicaid single payer experiment has been large scale. Under the direction of autonomous state leaders, 77 million have received care of late with extraordinary high satisfaction levels. 34 million of these citizens are children. 2 million new citizens will be ushered into the human race this year through Medicaid prenatal and obstetric coverage. 9 million blind and disabled citizens sleep easier each night thanks to the governors. By 2026, absent Trumpcare regression, the 77 million will grow to 86 million with 35 million children in the ranks. Nearly a third of the states structure offerings through a managed care approach. All integrate physical and mental health, including addiction services.

Governors like Kasich have turned a critical eye toward waste. For example, Medicaid has historically been the primary payer of long term care – specifically nursing homes. Over decades, perverse incentives have created a lawyer and nursing home industry driven cottage industry designed to divest seniors of their assets so that they could reach eligibility requirements to have free nursing home care. Nearly half of all spending  for long term care in the US – over $150 billion a year – comes from Medicaid. Flexibility provided to governors like Kasich could allow the realignment of financial incentives with funds provided for home services to multi-generational families who do right by their seniors rather than abandon or warehouse them.

Innovative programs like Money Follows the Person or The Program of All-Inclusive Care for the Elderly (PACE) should not be confused with the Senate Republicans offerings. Their caps have little if anything to do with innovation and more to do with transferring some $800 billion over the next 10 years from the neediest to the wealthiest Americans in the form of tax cuts.

Trump and his followers may be intent on creating chaos, promoting regressive legislation, and reimagining reality, but governors in most states are laser focused on solutions – and the more they experience single payer efficiency, control, and integrated health planning, the more they and their citizens like it.

 

Doctor Senators Barrasso and Price – They Are No Royal Copeland.

Posted on | July 14, 2017 | 1 Comment

Sen. Royal Copeland M.D. (D, NY)

Mike Magee

This week the Republican leadership once again released an unapologetically regressive plan for America’s healthcare that would drive a further wedge between rich and poor and sow despair deep into America’s soul. Sadly, two of the primary leaders of the effort are fellow physicians, Sen. John Barrasso (R,WY) and former Sen. Tom Price (R, GA). This in the same week that we learn that America’s childhood go-to staple, Kraft boxed Mac & Cheese, has been laced with endocrine disrupting phthalates all along and no one seems to have noticed.

Barrasso and Price stand in steep contrast to other historic physician legislators. For example, in 1932, with FDR fully in charge and the New Deal gaining momentum, Walter Campbell, the director of the FDA, and the Assistant Secretary of Agriculture, Rexford Tugwell, put a proposal in front of FDR to strengthen the enforcement powers of the 1906 FDA law. Their ally in Congress was a physician and former New York City Commissioner of Health, now senator from New York, Royal S. Copeland M.D..

Copeland gave it his all, but it was an exercise in futility. To begin with, he was opposed by a wide range of interests from food to drug manufacturers to cosmetic makers. But more importantly, the newspaper and magazine publishers viewed “over-regulation” of this free wielding American sector as an existential threat to them. After all, the advertising dollars spent by every Tom, Dick and Harry with a “miracle cure” were considerable. And that was without counting the food manufacturers whose wallets were wide open as they worked to establish their various national brands. To these publishers, tighter health controls meant tighter marketing budgets. To make matters worse, the Copeland supported legislation would involve itself in regulating the murky area of “false advertising”, and “who knows where that could end”.

But the truth is that at the time the various commercial interests were not too worried about the FDA’s Walter Campbell, or his boss in Agriculture, Rexford Tugwell, or even the Senate’s Royal Copeland. Health legislation was low on the list of priorities in FDR’s New Deal. It was going nowhere fast – that is, until October 11, 1937. That was the day that the American Medical Association was informed by one of its physicians that a number of children in Tulsa, Oklahoma had taken a new sulfanilamide liquid medicine and died.

AMA labs quickly identified the killing agent as diethylene glycol used as a mixing agent in the elixir of sulfanilamide produced by S.E. Massengill and Co. in Bristol, Tennessee. The mix had passed the taste test of the company’s chief chemist, but he had somehow missed that diethylene glycol was a known poison used in anti-freeze. At the time, no safety tests were required before release of medicines on our citizenry.

“Elixir Sulfanilamide” was rushed into production and distributed widely. 240 gallons of the red liquid made it’s way to 31 states, through a web-like network with many small distributors. That was in early September, 1937. In all, over the next 6 weeks 100 children died. And their deaths were not simple. They were proceeded by 7 to 21 days of wrenching painful illness including “stoppage of urine, severe abdominal pain, nausea, vomiting, stupor, and convulsions”.

One young mother spoke for everyone affected in her 1937 letter to FDR:

“The first time I ever had occasion to call in a doctor for [Joan] and she was given Elixir of Sulfanilamide. All that is left to us is the caring for her little grave. Even the memory of her is mixed with sorrow for we can see her little body tossing to and fro and hear that little voice screaming with pain and it seems as though it would drive me insane. … It is my plea that you will take steps to prevent such sales of drugs that will take little lives and leave such suffering behind and such a bleak outlook on the future as I have tonight.”

Doctors, in a manner reminiscent of contemporary physicians who carelessly over-prescribed Oxycontin and ignited the current Opioid Epidemic, were remorseful as well. Consider Dr. Archie Calhoun, of Mount Olive, Mississippi, who wrote on October 22, 1937:

“Nobody but Almighty God and I can know what I have been through these past few days. I have been familiar with death in the years since I received my M.D. from Tulane University School of Medicine with the rest of my class of 1911. Covington County has been my home. I have practiced here for years. Any doctor who has practiced more than a quarter of a century has seen his share of death. But to realize that six human beings, all of them my patients, one of them my best friend, are dead because they took medicine that I prescribed for them innocently, and to realize that that medicine which I had used for years in such cases suddenly had become a deadly poison in its newest and most modern form, as recommended by a great and reputable pharmaceutical firm in Tennessee: well, that realization has given me such days and nights of mental and spiritual agony as I did not believe a human being could undergo and survive. I have known hours when death for me would be a welcome relief from this agony.”

The whole disaster was vigorously reported in the press, including the powerful New York media, home state of FDR, Chief Justice Hughes and Royal Copeland. It was a New York physician, learning of the AMA’s involvement on October 14, 1937, who first had contacted Walter Campbell at the FDA and got the policy ball rolling. As a result of the tragedy, the issue was now a New Deal priority and on everyone’s radar screen. Copeland and Campbell teamed up on legislation.

The AMA, the American Pharmaceutical Association, women’s groups and the national press all closed ranks in support. It didn’t hurt that the main Congressional opponent of Royal Copeland’s legislation was Representative Carroll Reece from Tennessee, home state of the S.E. Massengill Company. Copeland harnessed the power of the media writing an impassioned editorial in Scientific American where he detailed the deficiencies of the 1906 law.

On November 16, 1937, Senator Copeland formally addressed the tragedy on the Senate floor and asked the Department of Agriculture, which had jurisdiction over the FDA, to issue a formal investigative report on the tragedy.  Over the next six months he worked tirelessly on corrective legislation. By June 11, 1938, bills from the Senate and House of Representatives had been reconciled, and on June 25, 1938, FDR signed into law the 1938 Federal Food, Drug, and Cosmetic Act.

A Nation At Risk This 4th of July!

Posted on | July 2, 2017 | No Comments

SOURCE: Decline in State/County GPA from Global Warming

The fact that the US is the only developed nation in the world that spends more on Health Care than all other Social Services combined according to a 2015 Commonwealth Fund study is a remarkably regressive achievement. Besides reflecting our distorted financial and ethical priorities, and the natural end point of a profit-driven free enterprise health care system, it also defines our nation’s vulnerability.

There is growing realization that our inability to come to grips with a decision way back in 1947 to throw our weight behind private profiteering health insurance has the potential to soon crowd out all other US priorities and collapse our economy. A simple shift to consolidate back room insurance functions (not the management or delivery of care) could trim 15% off the US health care bill immediately. But more than this, it would allow us to develop for the first time an integrated plan to assure a more healthy America.

Under such a plan, medical schools would integrate social mission into health professional education as Fitzhugh Mullen recently suggested. Also regressive policies such as those proposed by Trump EPA chief Scott Pruit would be exposed for what they are – economically dangerous and ethically disastrous.

As we wait for the US populace to catch up with this administration (in much the same way as 1970 America’s Nixon supporters took 19 months to finally come to grips with the fact that their President was simply not well enough to manage the duties of Presidency), we all need to continue to expose the truth in words and graphics.

Paul Voosen, Earth and Planetary Science journalist for Science magazine does his part in the June 30, 2017 issue of Science. The graphic above depicts the loss in state and county GDP as a result of the predicted impact of global warming under the current regime. It mirrors in part the human carnage of the opioid epidemic, and the supreme irony that Trump’s loyalest supporters are those most at risk as a result of his regressive policies.

As Frank Rich encourages in this week’s New York magazine cover story, “How A Presidency Ends”, it is highly likely that Trump will come to the same end as Nixon. But only if patriotic Americans continue to doggedly and respectfully pursue, display and share the truth in red, white and blue.

Happy July 4th!

The Secret To Making America Healthy – K.I.S.S.

Posted on | June 26, 2017 | 2 Comments

Mike Magee

As the debate over health care in America rages anew this week, the great lie oft repeated but never defended is that our system is too complex to wrestle to the ground. That is the lie, reinforced over half a century, that has left our citizens and now our entire economy at risk. The truth is, the solution is rather clear, the resources available, and the liability of continued inaction of mounting concern.

How do we make America healthy? Before we address this critical baseline question, let’s first tackle another, “Why should we make America healthy?” The answer to this question could go on for pages but the short-hand response is that healthy citizens maximize human productivity and societal stability. If the idea is to make America as great as it can be, then healthy citizens are the starting point.

So, how do we make America (and Americans) healthy? Whatever we decide to create and provide in pursuit of this fundamental goal, it must be universally available to all citizens. This is because we are an inter-dependent species. We are only as well, or as productive, effective and mutually supportive as the weakest link in our chain. Insecurity breeds insecurity. Fear and dislocation breeds fear and dislocation. Despair undermines our collective futures. So whatever we offer to promote and assure a healthy America must be available at the outset, and with certainty and simplicity, to each and every one of our citizens.

Logic dictates that the execution and management of this offering should be designed to consume as few resources as is humanly possible. The more we consume in the offering and financial management of universal basic health coverage the less will remain for actual services. This simple reality is why most nations have centralized the primary back room functionings of health coverage and financial administration. Where most industrial nations (and our own Medicare) consume 5% to 10% of total health resources on this first step, our complex free-enterprise and employer dependent approach to the offering consumes as much as  25% of total resources while failing to ensure universal coverage.

If all must be covered, and the administration of the offering must be a public and centralized responsibility to assure accountability, uniformity, and cost-effectiveness, that leaves the definition of services and the actual delivery of services. These need not, and some would argue should not, be centralized. A basic package of services should be required of all, and not all services are affordable or even desirable. For example, Canadians universal health plan covers on average 70% of the total cost of health care for Canadians. The plan does not cover pharmaceuticals, optical needs or dentistry. Citizens who wish to can purchase private supplemental plans to cover these costs. Furthermore, plans total offerings vary from province to province, as defined by budgets and priorities set by provincial governments year to year. Hospitals are funded by the provinces, and doctors (who on average make more than American doctors) are largely reimbursed fee-for-service. Ample leeway, state to state, as we see with Medicaid, could be offered to allow a reasonable amount of experimentation and choice.

This combination of central control and management of insurance coverage and local responsibility for budgeting, prioritization, and quality assurance has consistently outperformed America’s purposefully complex free-enterprise health sector free-for-all for over a half century. Our approach underperforms by almost every health measure, costs nearly twice as much, and has patient satisfaction ratings of only 25% in the latest polls. We have paid dearly for our complexity in funding an astonishing array of “non-real work”. For example, we support nearly a half million individuals selling and managing health insurance in the US, and and equal number of hospital and physician office coders and billers on the other side working diligently to get payments out of  the mostly for-profit insurance companies.

Vannevar Bush

But our fundamental error or conceit dates backs to 1947, as we exited WWII and considered how best to manage an enormous chronic burden of disease. Lead by Vannevar Bush, whose military approach to scientific collaboration had provided new blood products, penicillin, and the atomic bomb, our leaders concluded that a similar unencumbered collaborative free-enterprise approach could defeat disease as it had defeated the Nazis. By omission, their definition of health was the absence of disease. Defeat disease and health would be left in its wake. Fund the effort on the backs of employers and unions as a benefit, and ignite collaboration and a collusive integrated career path with federal dollars and enabling patent legislation and victory was assured.

In contrast, Canada took the time to earnestly ask “How do we make Canada (and all Canadians) healthy?” In response, they created universal coverage and continuously refined their answer to this basic question. By 2010, prevention, not intervention, surfaced as mission central. They stated then that “Health promotion is everyone’s business. While it is clear that health services are a determinant of health, they are just one among many. Others include: environmental, social and economic conditions; access to education; the quality of the places where people live, learn, work and play; and community resilience and capacity.”

It really matters little whether Republicans prevail in their regressive efforts to reinforce over a half century of failed health care policy. The die has been cast. As Warren Buffett recently stated,  “Medical costs are the tapeworm of American economic competitiveness.” The cost and inefficiencies have been well documented including:  High administrative costs with 850 health insurance companies selling to millions of employers; high costs passed on to employees in rising contributions and lost wages with the burden weighing more heavily on low income employees; employees of small firms and the unemployed/underemployed left out of coverage; employment based insurance the major contributor to bankruptcies and poor labor relations; and finally a coverage system that discourages worker mobility and advancement. Together, these fatal flaws in a single sector of our society are bringing us to our economic knees.

Whether now or in the future, we will be forced to ask that simple question, “How do we make America (and Americans) healthy?” In responding, we will not be limited by resources. More than ample resources, currently misapplied, have already been dedicated to these services. We need only to recognize that health is not the absence of disease, and mirror Canada’s 2005 proclamation: “As a nation, we aspire to a Canada in which every person is as healthy as they can be—physically, mentally, emotionally and spiritually.”

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