health insurance does not equal health

Tuesday, August 1, 2017

Dear Politicians. Let me ask a question. If every person in our country had health insurance, would we be any healthier?

-Mark Cuban. Twitter. 7/30/2017

Dear Mark,

Thank you for such an insightful question. Unfortunately, I am not a politician and cannot provide you their perspective, but I do care for patients on weekends, in the middle of the night and whenever they perceive an emergency to exist.  And I wish that I had a satisfying and uplifting answer toyour question. But I do not. The reality is that health insurance and access to health care does not equate to health. This is not an opinion based upon fact but instead, from anecdotal personal experience and bolstered by a few cherry-picked statistics.

Ideally, access to health education and disease prevention would begin before birth and continue through childhood and adolescence so that each person was delivered to adulthood with the best chance of living a healthful life. The concept that health insurance availability alone will reach such a goal fails to account for societal ills and governmental agency policies that are add odds with providing a highway to healthy adulthood.

Beginning with pregnancy, there are too many unlucky babies born to mothers who abused alcohol, opioid narcotics or tobacco during pregnancy. The numbers can be staggeringly high.

  • 21,700 babies were born in 2013 (latest statistics available from the CDC) with neonatal abstinence syndrome, where the newborn goers through narcotic withdrawal because of the mother’s drug abuse. Short term complications include poor growth, dehydration and seizures; the long-term problems are uncertain since there is not enough data yet available.
  • Fetal alcohol spectrum disorder affects between 0.2% and 1.5% of all births in the US. In 2002, the lifetime cost per infant was more than $2 million and a yearly cost to the health care system of more than $4 billion.. In some western European countries, the incidence of fetal alcohol syndrome can be as high as 5%. It seems that universal healthcare can’t stop the adverse effects of alcohol abuse.
  • 10% of mothers smoke during the last 3 months of pregnancy. This affects placenta development and can lead to premature deliveries and low birth weight babies. Other issues include congenital heart problems and cleft lip. There is also increased numbers of asthma, pneumonia and SIDS (sudden infant death syndrome)

Tobacco continues to rear its ugly head in teenage years, when most people begin smoking. More than 90% of people have their first cigarette before age 18. Each year more than 450,000 people die from smoking related deaths, from cancer to heart attack and stroke, to COPD and emphysema.

“The overwhelming amount of death and disease attributable to tobacco is caused by addiction to cigarettes – the only legal consumer product that, when used as intended, will kill half of all long-term users,” – FDA Commissioner Scott Gottlieb

And not to be forgotten, the cost of alcohol abuse in lives lost and broken. More than 10,000 people die each year as victims of a drunk driver. 1.1 million people were arrested for drunk driving. In Wisconsin, known for its beer and binge drinking, there were more than 5,100 alcohol related crashes in 2015, resulting in 2,872 injuries.

US obesity rates have increased to affect nearly 40% of all adults and 17% of all children. Complications include heart attack, stroke, diabetes, sleep apnea and cancer.

Mr. Cuban, you’ve asked a profound question. Regardless, of how many people have health insurance, there is no guarantee that they will pursue a healthy lifestyle. The question then might be asked whether personal choice should affect access to the full spectrum of possible health care available. Most recently, one health authority in England has decided to withhold elective major surgery from people who are morbidly obese or who smoke.

When Congress debates the merits of one health insurance system over another, they forget to consider perhaps the most important intangible. There is an unlimited and insatiable demand for health care and unless society is willing to pay for it all, one day, choices will have to be made about who gets what care.  Welcome to the world of rationing.

SIncerely,

Ben

 

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you can pay me now…

Sunday, November 6, 2016

For football fans, there is nothing worse than a penalty that wipes out a touchdown or erases an interception. Coaches and players work on execution and avoiding errors, especially those that are self-inflicted by penalty. The team that makes the fewest mistakes tends to win the game. So it should come as no surprise that in the real world medical care, the doctor and patient who minimize their error tends to win as well. But while football has officials on the field and in the replay booth, making the right call for medical care is tougher.

Medicine is all about delayed reward. Controlling diseases like high blood pressure, high cholesterol and diabetes can increase quality and quantity of life. But the health care community can only give advice; they can’t go hope with the patient and demand the patient do the right thing. And there are no referees to throw a flag and call out actions that can erase life’s touchdowns.

Some behaviors are not well known and tough to fix. Medications for chronic diseases are supposed to be taken on a regular basis to prevent complications. High blood pressure, high cholesterol and diabetes medications (including insulin) are used to control these diseases to prevent complications. Heart attacks, strokes, blindness and amputations are potentially preventable, but the reward for taking a pill and watching what you eat is 10, 20 or 30 years down the road. Not taking medicine has no upfront risk and there is nobody in a replay booth reminding you to take your emaciation every day.

What is the cost? Individually, it can be an early death or significant disability. For the society, research suggests that failure to comply with medication prescriptions increases medical costs by up to $290 billion a year. 20-30 percent of all prescriptions go unfilled and up to 50% of the time, medication is not taken as directed. This leads to up to 10 percent of all hospital stays and more importantly, 125,000 deaths a year.

Specifically, for diabetes, the numbers are even worse. For those who need medication, not keeping blood sugars under control can increase deaths directly related to diabetes by 50%, and the noncompliance rate does not count deaths from heart disease or kidney failure.

Some behaviors are easy to see and still tough to make better. Drunk driving is unacceptable behavior and it is a societal norm not to drink and drive. Yet while police and the courts are there to throw yellow flags, more than 28 million people admit to that behavior every year and it leads to almost 10,000 deaths a year. Smoking is a behavior that has no positive benefit to the body, and is highly addictive. There are 1 billion smokers worldwide, it directly kills 5 million people a year (167,000 cancer victims in the US) and indirectly kills another 500,000 from second hand smoke. There is no striped shirt blowing the play dead when a person buys a pack of cigarettes.

Why do we care what other people do? The bottom line is that we are our brother’s keepers and resources that are spent on avoidable cancer care, dialysis for kidney failure or nursing homes for stroke victims might be better spent on primary care, preventive medicine, providing good nutrition for the poor and better mental health for those in need. But it’s tough to tell people who have self-inflicted their disease or injury, that society will not look after them…so we pick up the pieces and try to put them back together again. Sometimes, again and again and again.

Financial resources are not unlimited. Taking money out of one bucket, to care for behavior errors leaves less in other buckets. Once upon a time there was a wise commercial for Fram oil filters to increase your cars longevity:

“you can pay me now…or you can pay me later”

 

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