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	James L. Holly, M.D.

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Your Life Your Health - Is America's Health Care System "Sick"?

James L. Holly,M.D.

April 19, 2007

Your Life Your Health - The Examiner

Jonathan Cohn's new book, Sick: The Untold Story of America's Health Care Crisis-and the People Who Pay the Price, is provocative in title and content. As I listened to the tragic story of the Duke Lacrosse players on 60 Minutes April 15, 2007, I thought of Cohn's book. The interviewer asked telling questions and examined this travesty of justice, but failed to address the most fundamental question. On many levels, this situation was a tragedy for the accused and for the accuser. The actions of the prosecutor were reprehensible. Yet, for all of the questions, the interviewer failed to ask if the three young men had ever regretted their decision to hire a mother to perform a striptease for them. No one has commented that the accusations could never have been brought if the young men had not willfully and wittingly put themselves into the vulnerable situation they created. Doubtlessly, many have found themselves falsely accused when they did nothing to create the opportunity for the false accusations but in this case no such innocence existed. And, it is these two extremes which provide a context for our discussion of Cohn's book and proposed solution.

Unlike the Lacrosse players, who while innocent exposed themselves to the risk of accusation, many people are sick without any contribution or fault of their own. They did nothing to contract the illness, or they did nothing to cause the illness. Cohn's paradigm of a "sick healthcare system" has little to offer in these cases. In some of his illustrations, people failed to get health care because they failed to seek care. The present healthcare system cannot be faulted - even in the face of no insurance, when a patient with an obvious and serious healthcare issue does not seek care. Granted responsible people could delay seeking care which they know they cannot pay for, but the healthcare system in American has a grand tradition at many levels of providing care for those who cannot afford it.

Another question which provides fodder for Cohn's book is, "Does preventive medicine help keep the costs of healthcare down? Cohn's response:

"The more you encourage healthy behavior, the more you're going to head off big costs down the road. And good universal health-care systems emphasize preventative care. But the debate we've been having about individual responsibility and medical care has been framed in an unfortunate way. It's very nice advice to say we should all eat healthy and work out three times [a week], but good luck doing that when you're a single mom who works 12 hours a day. And don't forget the enormous role that genetics plays in health. Eating a high-fat diet will drastically increase your risk of a heart attack, but so will a family history of high blood pressure. I don't think we really want to start penalizing somebody financially because his grandma has a predisposition to high cholesterol."

Here is the problem with Cohn's thesis and with government-sponsored healthcare. First, preventive care is most often thought of in terms of something which is done to, or for a person, rather than something the person does for himself. The reality is that preventive care is both. It is not without a point that this column is always concluded with the statement, "Remember, it is your life and it is your health." The primary and ultimate responsibility for excellent health must reside with the patient. The burden upon the patient cannot be easily dismissed with Cohn's statement "the more you encourage healthy behavior, the more you're going to head off big costs down the road." That is the hope, but it has not yet been proved in population studies which are large enough to significantly affect the national healthcare budget. And, in circumstances where it has been suggested that people ought to be partially coerced into health life styles, cries of freedom have arisen to free people to continue unhealthy lifestyles while expecting others to pay for the consequences of those life styles.

Cohn's second point is that the burden of living often prevents a patient from adopting preventative-health life styles. He said, "It's very nice advice to say we should all eat healthy and work out three times [a week], but good luck doing that when you're a single mom who works 12 hours a day." When you start giving people exemptions from personal responsibility for their health, you have lost the battle. When one person is given a pass from healthy eating and exercise, everyone will ask for the same pass and they will feel justified in doing so.

Cohn's third premise is that everyone with a positive family history should be given a pass, he said, "Eating a high-fat diet will drastically increase your risk of a heart attack, but so will a family history of high blood pressure. I don't think we really want to start penalizing somebody financially because his grandma has a predisposition to high cholesterol." Yet, the facts indicate that what he says is not necessarily true. The Amish have a very high fat-content diet and they have a very high calorie diet - the two almost always go together - but they have a low incidence of heart attacks and of obesity. Why? They walk. They don't exercise and they don't go to the gym. One study showed that the average Amish man walked over 16,000 steps a day.

Genetics, it has been said, "loads the gun," but environment and habits "pull the trigger." Simply stated, except in rare instances of dominant traits which have almost a 100% expression, genetics places us at risk but it is our choices which most often result in disease. Even cancer, for which you may be at higher risk genetically, often requires bad habits to find expression in overt disease. The genetic predisposition for a particular condition does not mean that you will always have that disease but it will tell you how aggressively you should employ the preventive health initiatives available to you, among the most important of which are: Lose weight, Exercise, Stop Smoking.

If Mr. Cohn thinks the public's reaction to President Clinton's health initiatives was adverse, wait until he sees how people resist forced lifestyle changes for health benefits which benefits are years in coming. It may be that healthcare initiatives are stymied by unconscious ideals which run through our entire society. One historian posited the thesis that "the frontier" defined the character of America. With our entitlement mentality; with our delicatessen approach to healthcare and with the rugged individualism of the frontier mentality, America may have unique healthcare pressures which are defined by non-medical ideals.

It is here that Peter Senge's concepts in The Fifth Disciple are important. While Dr. Senge's work was written to analyze business strategies, it applies as well to both the organization of healthcare and to healthcare decisions made by individuals. Senge said: "System thinking is needed more than ever because for the first time in history," because "humankind has the:

Capacity to create far more information than anyone can absorb,
To foster far greater interdependency than anyone can manage
To accelerate change far faster than anyone's ability to keep pace."

Complexity can easily undermine confidence and responsibility. The simple question of whether women ought or ought not to take hormones is a case in point. The more you read, sometimes it seems the less you know about what you should do. Senge identifies several kinds of complexity but the most important is "dynamic complexity," in which cause and effect are subtle, and the effects over time of interventions are not obvious. This is what happens when a healthcare provider tells patients that if they will Lose Weight, Exercise and Stop Smoking, their health will improve. The observable health benefits are not immediate.

In a recent interview, Cohn said:

"If you study other health-care systems in Europe and Japan, they all have managed to give insurance to everybody and at the same time spend less money than we do so, right off the bat, they're accomplishing something that we're not. And while the health statistics vary, overall the medical care seems as good if not better."

The first part of this can be quantified. Of course, we can give insurance to everyone, if it doesn't cover anything. However, comparing "amount of money spent," even if you define it as per capita expenditures, doesn't help unless you define what is available to the individual. None of these details are given by Mr. Cohn. When you add the subjective concept of "better," the complexity increases geometrically and analytical problems abound.

Mr. Cohn states, "The high-end care in Paris is just as good as the best hospitals and doctors in New York City." Of course, "high end" care is not available to everyone. He concludes this part of his discussion with the comment, "And, you always hear about waiting lines with universal health care-Britain has them, Canada has them. But other countries with universal health care don't seem to have systematic waiting-line problems. And France is one of those." If you are going to have a serious discussion about healthcare delivery, you can't use phases like "don't see," and the absence of "waiting-lines" can just as easily relate to what is not available as to what is done.

Cohn was recently asked, "What makes you think a government health insurance plan wouldn't also start out as idealistic and well-intentioned and then go bad?"

"Government doesn't answer to shareholders, it answers to the voters. I'm not naïve-government can be corrupt and manipulated, and I'm not trying to say universal health care is perfect. But I think it can be a lot better than what we have now. Look at the Medicare system. It has plenty of flaws, but it's still way better than private insurance."

And, "How could the government afford health insurance for all those people?"

"At the end of the day, if we want universal health care, we're going to have to pay more in taxes. By definition, we're talking about the government assuming a greater role for health insurance. It can't do that without money. But that's only half the story: we'll also be asking private insurance to do less, which means premiums will come down and paychecks will go up."

Do you remember the joke, "Welcome to healthcare by the same people who brought you the postal service." Well, the post office is running pretty well now, but only after it is virtually privatized. I would like all that believe that insurance premiums will go down if the government takes over healthcare to come to the front line. By the way the line leads to a big cliff.

America has sick people, and they are getting sicker for many reasons. One is they are getting older because of advances in healthcare. Another is that Americans are eating more and exercising less. The list goes on. Is America's Health Care System "Sick"? No, but in the coming weeks we will examine some ways in which it can be improved. Remember, it is your life and it is your health.

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