Random Thoughts from a Restless Mind

In any discussion or debate about a “Big Idea” the quality of the discourse depends in part on the accuracy and specificity of the definition of terms, as well as the amount of agreement among the participants as to the actual question or idea that is under consideration. When the discussion is proceeding with the goal of establishing a solution to a “Big Problem” or crisis, it is also useful to have performed a root cause analysis of the crisis so that one can assess whether the “Grand Solution”  is targeted at the true problem or simply aimed at a symptom of that problem (hey…I’m a doctor…I can’t help myself with the medical analogies). In short, in order to avoid the all too common trap of “talking past one another”, participants in this type of discussion must agree on premise and definition before embarking on the journey.

Unless, of course, the participants are politicians, government bureaucrats, or other creatures who feed with them and upon their offerings.

We are being bombarded with articles, speeches, broadcasts, and Tweets about the “Health Care Crisis” in America. In my reading there seems to be at least a dozen separate discussions occurring under this heading, mostly due to the fact that the above two rules about premises and definitions are being ignored, either inadvertently or willfully. So why don’t I offer up a couple of definitions that will allow us to explore the root cause of this so-called “Health Care Crisis”? Who knows? Perhaps a solution might arise.

Loosely defined terms allow a type of linguistic abuse in “Big Idea” discussions; this abuse usually involves some sort of secondary gain (money, power, legacy). The more loose the definitions the more abuse made possible. What is meant by “Health Care” and what should the definition really be? At present “Health Care” when combined with the term “Crisis”,  means the cost of providing health care. “Health Care” is properly defined as the provision of medical care, cognitive, diagnostic, and procedural, that actively prevents or cures disease.  I think anyone who has been paying attention would agree that we might very well have a “Health Care COST Crisis” in America right now. It’s really expensive to provide  health care to  everyone who needs it in America.

Do we have a “Health Care Crisis” in America? Are our hospitals, our doctors and our nurses providing inadequate or bad care? Pundits, politicians, and plain old people on the street point to the fact that the United States does NOT have the highest life expectancy among developed countries and say that the answer must be “yes”. They point out the regional discrepancies in treatment protocols and health care expenditures and say that this is proof that healthcare providers are not providing the best care possible. I would argue just the opposite. The actual “Health Care” that is provided in the United States is superior to that provided anywhere else in the world. I will show in a minute that this is actually part of the “Cost” problem.

These same people  then point to the fact that, at any one time, some 47 million Americans are without “Health Coverage”, what we call health insurance, and that this lack of financial coverage preventing them from gaining access to health care is causing  preventable deaths. These preventable deaths explain the lower life expectancy of Americans in comparison with, say, Swedes. It turns out that this, too, is a canard. A red herring. Americans without “Health Care Coverage” do in fact have access to health care, and access to “Health Care Coverage” or health insurance does not appear to affect life expectancy.

No matter how you slice it this discussion or debate comes right down to the most basic definition, which then establishes the most basic root cause of the problem. We do, indeed, have a “Health Care Cost Crisis” right now in America, but it all stems from the undeniable fact that we have a “HEALTH CRISIS”, and it’s getting worse. Our people are more and more unhealthy and our phenomenal ability to care for their diseases is allowing them to live unhealthy lives longer. This  allows us to spend more money on keeping them alive.

The Eight Americas Study published in the People’s Library of Science examined life expectancy in America and the factors that influence it. (http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0030260) The population of the United States was divided into 8 cohorts based on age, race, county of residence, race-adjusted income, and cumulative homicide rate. Cause of death was recorded and variables such as whether or not the individual had health insurance were tabulated. The difference between the longest lived cohort  and the shortest-lived is 35 years! The results are as surprising as they are counter-intuitive. While income is a weak factor underlying this difference neither “Health Care Coverage” nor access to health care is a factor.

“The eight Americas analysis indicates that ten million Americans with the best health have achieved one of the highest levels of life expectancy on record, 3 yrs. better than Japan for females and 4 yrs. better than Iceland for males. At the same time, tens of millions of Americans are experiencing levels of health that are more typical of middle-income or low-income developing countries… The health disparities among the eight Americas cannot be explained by single causes of death such as homicide or HIV. Nor are the largest sources of disparity in children and the elderly. The mortality disparities are most concentrated in young and middle-aged males and females, AND ARE A RESULT OF A NUMBER OF CHRONIC DISEASES AND INJURIES WITH WELL-ESTABLISHED RISK FACTORS.” (emphasis added)

Yes, we have a Health Crisis in the United States. It is a crisis born of preventable injuries and disease (vehicular accidents, alcohol-related homicide, diabetes, heart disease) with actionable underlying causes and risk factors (alcohol abuse, tobacco use, obesity). We have aided and abetted this Health Crisis because we do NOT have a Health Care Crisis; it is precisely our ability to treat many of these diseases that keeps many unhealthy Americans alive. We bear the financial consequences of this Health Crisis as a nation.

The solution to this problem becomes rather clear once we have the appropriate definition of the problem and once we identify the underlying cause of the problem. It appears that we cannot afford to pay for all of the health care that will be necessary to keep Americans alive if we continue to go on with things as they are; we have a “Health Care Cost” problem. The root cause of our financial problem is that a large percentage of Americans are not healthy; we have a “Health Crisis” and this is largely due to problems that can be prevented. No amount of “Health Care Reform” that involves changes in how we pay or who ultimately pays for healthcare will solve our “Health Care Cost Crisis” unless we solve the underlying problem of unhealthy Americans. The solution to this problem is a PUBLIC HEALTH  strategy that will improve the health of Americans, and it is here that funding and reform should occur.

Now, when this inevitably  fails to occur because there is no near term secondary gain to be had  we can have a discussion about the “Leadership Crisis” in America.

This entry was posted on Thursday, June 18th, 2009 at 11:40 am and is filed under Health Care, Healthcare Economics. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.