Two Reforms Still Needed for an Effective US Health System

I wish to begin with a Groucho Marx joke: “Did I ever tell you how I shot a wild elephant in my pajamas? How he got into my pajamas I’ll never know.” In this country, health care system reform is getting more attention than Michael Jackson, Walter Cronkite, Lance Armstrong and that unhinged professor who protested too much, just because the police, in his living room, demanded he identify himself and be polite about it. What a nerve. All the fuss about health system legislation is a good thing, but it would be a much better thing if proposals took notice of the proverbial elephant in the room (but not anyone’s pajamas), which the experts and politicians alike seem determined to ignore. Except me. I will describe the elephant in just a moment. First, a few observations about the maddeningly myopic health reform debate.

A major assessment of the situation appeared in the New York Times. The author took the view that all ideas favored by Democrats or Republicans share a basic flaw. I agree with that statement, but I don’t think the writer identified the correct flaw. According to David Leonhardt (“Health Care Reform and the Unpopular T-Word,” Economic Scene, New York Times, July 29, 2009), the flaw in all plan proposals is that none would raise revenue as quickly as costs will surely rise. (During the last ten years, the economy grew 20 percent; medical costs rose 50 percent.)

Well, that sounds like a flaw to me, too, but it’s not as devastating as the flaw (or unacknowledged elephant) that will trample any and all reform attempts, even IF revenues somehow rise in concert with but not much greater than medical costs.

The debate to recast the legislation one way or the other addresses all manner of topics, but focuses on the insurance mandate, controlling costs via efficiencies, as well as boosting access to care and improving the quality of services. Hello? What about boosting the sorry health status of the people? Why is this upstream situation given so little attention? Yes, everyone needs access to quality medical care at affordable rates in a system the economy (and taxpayers) can sustain. However, we must at the same time create conditions wherein Americans are prodded, motivated and helped to live so as to remain healthier longer and thus needful of less medical attention.

There are, in fact, two elephants in the room, both of which are equally ignored. I know – how the hell can politicians ignore something so impressive, so big and so loud (not to mention so dangerous) as two bloody elephants? To me, it seems inconceivable that this is happening, but to me a lot of things seem inconceivable. (I still find it inconceivable that George W. Bush was president of this country for eight years and that Sarah Palin was a major party candidate for vice-president.) But, I digress. Back to the elephants.

No, I don’t think it is what Senator Lindsay Graham identified when he said, Well, the big elephant in the whole system is the baby boomer generation that marches through like a herd of elephants. And we begin to retire in 2008. Wrong elephant, Senator.

The largest elephant is the fact that Americans have sorry lifestyles. Two-thirds of us are undernourished, overfed, underfit and overfat. Or, put in a more positive light, most Americans have not realized their potentials for well-being. There is less reason, exuberance and liberty than there would be if more citizens pursued REAL wellness lifestyles. In addition to the four under and over factors I just mentioned, most of us are overstressed and undercalm, overmorose and underhappy, overbored and underexuberant and underskeptical and overly superstitious. (The under and over dichotomies could go on at length but enough, already. I’m sure you get the point.) We are a society that does not make choices favoring health and optimal functioning. That is the larger elephant in the room.

Let me tell you a bit about the smaller elephant, also a substantial problem. It is nearly unbelievable that this huge creature is not being specifically addressed in reform discussions at the highest levels. Even if the larger elephant (sorry lifesyles) were not around, this smaller beast can only be ignored at great peril at reform prospects. Ignore this creature and no reform element will make much difference. In fact, overlook this monster and any reforms could render a very bad situation much worse.

The smaller elephant is obesity. OK, maybe most people can’t sustain REAL wellness lifestyles even if they knew of such an option and were motivated to pursue such lifestyles (big “ifs”). However, the lesser elephant (but still HUGE) could be addressed in the context of health system reforms. The cost savings would be immense.

According to the lead article in a USA Today article by Nanci Hellmich entitled, Obesity Is A Key Link To Soaring Health Tab, (July 28, 2009, page one), those 30 or more pounds over healthy weight cost the country $147 billion in weight-related medical bills last year. Consider some of the consequences of obesity, as noted in a government-funded report by RTI International entitled, Weight of the Nation highlighted in the USA Today story.

* About 34% of adults – more than 72 million – in the USA were obese in 2006, up from 23% in 1994, according to government data. Two-thirds of people in this country are overweight or obese.

* Obesity accounts for 9.1% of all medical spending, up from 6.5% in 1998.

* An obese patient has annual medical bills of $4,871 compared with $3,442 for a patient at a healthy weight.

* Obese patients on Medicare spent about $600 a year more in prescription medications than patients at a healthy weight.

* The average American is 23 pounds overweight and collectively, we are 4.6 billion pounds overweight. (Statement attributed to CDC Director Thomas Frieden.)

* Taxpayers picked up about half the $147 billion tab in 2008 through Medicare and Medicaid.

* Obesity increases the risk of heart disease, diabetes, several types of cancer and other diseases.

* As important, obesity and simple overweight costs in other ways, such as lower prospects for a dynamic life wherein one can experience more joy and happiness, success in life and other psychological advantages. Obesity is, according to the report cited, the single biggest reason for the increase in health care costs. The lead author put it this way: If you really want to rein in health care dollars, you have to get people dieting, exercising and living a healthier lifestyle.

As William Dietz, director of the CDC’s Division of Nutrition, Physical Activity and Obesity observed, Obesity is not a problem that is going to respond to a silver bullet or single solution. Comprehensive policy and environmental changes are needed.

The president could regain support for his own health plan reform concepts by including incentives for healthy lifestyles. This could entail benefit elements that promote wise lifestyle choices generally and specific features that would combat obesity specifically, particularly exercise, nutrition and related benefit subsidies conducive to appropriate body weight.

The president would, with this single addition, regain the high ground by putting something positive into play, namely, a message that Americans can do much better in looking after their own best interests. Initially, given the widespread nature of the obesity problem, he would be offering the overweight a little help from their government, given the stake all taxpayers have in citizen health status. This seems good for the president at this time, as support for his reforms (focused on access and cost) has fallen dramatically in recent weeks. (See Laura Meckler, Support Slips for Health Plan – Obama Push Faces Growing Doubts in Poll; Overhaul Advances in House, Senate, Wall Street Journal, July 30, 2009.) Mr. Obama’s new emphasis is consumer protection. He should add to that consumer enhancement of life quality.

In putting forward a legislative program that addresses the need for healthy lifestyles, provides support for healthy lifestyles and creates conditions conducive to healthy lifestyles, Mr. Obama would be calling attention to the elephants in the health system reform room. More important, a reform plan that assists all citizens to make better choices will lower costs and thus fund expanded access to care for everyone.