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Upstream from the health care reform debate

As I read about and watch the machinations of the legislative process, public commentary, corporate pushback on health care reform, I keep scratching my head and ask, “What is missing in this discussion?”

In my view, the conversation needs to change from “How do we pay for expanded and universal care?” to “What kind of care and health outcomes are we really looking for?” Like moving deck chairs around on the Titanic, focusing on how to reallocate resources in health care without looking at the causes of those costs is short sighted and potentially fatal. Upstream from the current debate are important foundational issues. If these remain unaddressed, it will result in failure of any attempts to reform our health care system.

These issues are:

  1. The important role of a societal commitment to health promotion, prevention, and lifestyle change.
  2. Health workforce reform to provide more primary care providers into the system.
  3. A renewal of our commitment to principles of integrative medicine including patient centered, low tech, high touch care, natural remedies, and acknowledgement of the body’s ability to heal itself.

I recently read and recommend to you an excellent, visionary book by Dr. Andrew Weil, Why Our Health Matters: A Vision of Medicine That Can Transform Our Future (New York: Hudson Street Press, 2009). I concurred with many of the points made in this thoughtful and provocative work. Politically and socially we have our eyes on the wrong ball in the current debate. Rather than trying to figure out how to finance and prop up a health care system that is ranked only 37th in the world but is at least twice as expensive as any other country, we need to change the questions we are asking. If we are on the par with Serbia in terms of outcomes, failing to provide care to many of our citizens, and at the same time seeing enormous profits made by health technology, pharmaceutical, and insurance firms, isn’t there something wrong with the picture? And how about the prospect of generating an enormous federal deficit to be paid for by our future generations to support a system that isn’t working well anyway?

Weil looks the problem as rooted in several myths we seem to hold about our health care system:

  • Myth 1: Because America has the most expensive health care system in the word, it must have the best.
  • Myth 2: Our medical technology is our greatest asset.
  • Myth 3: Our medical schools and research facilities excel at creating the finest physicians and most productive medical investigators.
  • While acknowledging the strengths of US health care, Weil laments the tragedy of so much done at such high cost with such poor health outcomes. He points out the cost of technology and the folly of continuing to train more specialists for management of chronic disease. This is the current biomedical curricular culture which underemphasizes training in areas such basic, primary prevention and health promotion. The research enterprise meanwhile, though highly productive, is also highly beholden to industry support from pharmaceutical companies and other corporate interests. This creates inherent conflicts of interests that are highly concerning.

    We have neither created a society that incentivizes production of affordable, healthy food, encourages exercise, de-glamorizes tobacco, junk food, and alcohol, nor one that actively encourages healthy choices as a challenge to these cultural patterns. We have made some steps in this direction such a banning smoking in many public places and stocking school vending machines with more nutritious choices. We need to do more of this without creating an oppressive governmentally driven “nanny state” in which we are told how to live.

    Again, I concur with Weil that the way through this dilemma is to improve the health literacy of our populace. Addressing unhealthy eating habits, poor exercise patterns, obesity, and lifestyles that lead to the dysfunctions that precede chronic disease can only happen if we as a society understand the consequences of unabated continuance on our current path. We are all shocked at the occurrence of type 2 diabetes in obese children under 10 years of age. These children will be adults with premature vascular disease and heart problems in their 20’s and 30’s putting additional burden on their families and society. More medical care and pediatric endocrinologists aren’t the answer to this problem. Preventive measures at familial, school, community, and other social levels are our best first line of defense to this enormous problem.

    It is essential to create built environments in our communities so walking and cycling are encouraged as forms of exercise and commuting. Supporting organic and local farmers with purchasing healthier locally produced food is a way to encourage sustainability in agriculture that is healthier for us. We must also reduce huge federal incentives to agribusinesses that make cheap unhealthy food such as high fructose corn syrup and corn fattened livestock while healthy foods such as fresh vegetables, fruits, and lean meats from free range, wild caught, or organic sources are expensive. Such healthier foods are prohibitively expensive and largely unavailable for our most vulnerable lower socioeconomic neighbors who are disproportionately burdened with obesity, hypertension, diabetes, dyslipidemia, cardiovascular disease, stroke, and cancer. We know most such conditions can largely be prevented by lifestyle changes, improved nutrition, and better exercise.

    Ultimately, we must change the conversation about health care reform from saving a failing system that demonstrably doesn’t work. Mitigating the influence of pharmaceutical, insurance companies, and medical specialty societies is essential. We must expand the pool of primary care providers through changing education and reimbursement. Insurance policies must align with prevention and risk reduction rather than paying primarily for treatments, drugs, and testing. New preventive measures based on the principles of integrative medicine can help support an educated public to be motivated for such changes.

    Consumers and health care professionals must take responsibility not only for their own well being but for society’s though personal choices, involvement in legislative action, community change processes, and more. However, as Einstein warned, we must not “try to solve the problem with the same level of consciousness that created it.” Changing the conversation and asking key questions on what we want to do, should do, and must do for the health of our nation is the right thing to do. This trumps the endless wrangling over financing a dysfunctional system. How do we reduce the human costs of an American lifestyle that is promoting so much chronic disease? Only when we address such questions as these, we can create sustainable change. This is change not only that we can believe in, but live with