March 27, 2010
Health Care, Sick Care, and ObamaCareBy Michael Applebaum, MD
There are simple reasons why the ObamaCare approach to sick care reform can never and will never work to accomplish its stated goals of cutting costs while increasing access.
The simple truth requires neither confusing numbers nor rhetorical flourishes. The simple truth requires the lowest level of common sense and an answer to the question, "What is the essential work of the sick care industry?"
The answer to this question is a condition precedent to formulating any type of sick care reform scheme.
Yet not a peep was heard from the media about any discussion of this threshold matter.
To lay the foundation, let us consider two other questions: "What is health?" and "What is health care?"
One thing that health is not is the absence of disease. The state of health is currently unknowable by an individual. Even as I write this and even as you read this, either one or both of us could have a golf ball-sized cancer of the pancreas and not know about it.
Although each of us may feel "Fabulous!" as he is unaware of his respective pancreatic cancers, we are not healthy. Once we are aware of our pancreatic cancers, we know that we are not healthy because we feel sick. "Sick" is knowable; "health" is not.
It is not possible to explain the meaning of something with an unknown.
So what is health?
"Health" is a statistical concept. Health is the likelihood of developing certain bad illnesses. The better your health, the less your likelihood. The worse your health, the greater your likelihood.
Hence the description of disease and subsequent mortality as "risks."
"Health care" is what one does in the comfort and privacy of his home and in his activities of daily living. Good health care comprises those things done in order to lessen the likelihood of developing certain bad illnesses -- that is, one cares for one's health.
In many ways, health care is like integrity -- it is how a person behaves when no one is watching.
Sick care, or medical care, is what the sick care delivery system provides.
The system operates within the language of illnesses/conditions and procedures related to those illnesses/conditions.
The essence of the sick care system is repair and rescue. A person perceives or has an illness/condition and enters the sick care system to have the problem fixed.
Physicians (and other sick care professionals) are trained to fix certain problems that afflict patients. They have no control, and likely no substantial influence, over those behaviors that increase the likelihood of developing the kinds of troubles that they were groomed to repair. To this, the profession admits.
(Incidentally, arguably, they wouldn't really want to, anyway, unless it was to promote bad health care behaviors. For more information, see Shaw, George Bernard. The Doctor's Dilemma.)
With a repair and rescue industry, it is reckless to believe that there is a cost savings by opening it to more broken products to be fixed at more repair shops and by hiring more repair technicians. This is the essence of the attempts at sick care reform -- proliferating people-patching.
It cannot succeed.
Let us use the automobile repair industry as an analogy.
If the status quo of the automobile repair industry is altered to allow 30,000,000 additional vehicles into the system, then the number requiring repairs will have to increase. It would be silly to expect otherwise. Not all vehicles will operate perfectly for all time.
In the case of sick care, assuming the 30,000,000 entrants-to-be are like those presently in the system, then more than two-thirds of the adults are already set-ups for chronic and expensive illnesses/conditions needing repair. Under the same assumption, more than one-third of kids are set-ups for chronic and expensive illnesses/conditions needing repair. These are low-end figures.
Continuing with our car analogy, to service the 30,000,000 additional vehicles, it is reasonable to expect that more repair shops and personnel will be needed to effect the repairs. This could be untrue only if the repair shops over-hired personnel to such a degree that a substantial number of repair professionals were sitting around with nothing to do and receiving full income.
In the case of sick care, it appears as if the population of repairpersons is not in excess of what is currently needed (before the additional 30,000,000), and more will be required to provide repair and rescue services. Thus, there is no such slack.
It is clear that to deal with more people, more repair shops (medical establishments) and more repair personnel (e.g., physicians) will be needed.
More people charging for services must increase the total costs of the repair industry.
A real life, real-time experiment in this is being conducted by Toyota Motor Sales, USA, Inc. The company is undertaking the repair and rescue of over eight million additional products. We will have an opportunity to observe the effects of increasing the number of additional clunkers on the bottom line. A reasonable prediction is that the recall will not produce savings or profits for Toyota.
Therefore, unless the repair techs are paid less or restrictions on repairs are placed, or both, there can be no cost savings. Cost-shifting -- for example, having a neighbor pay for another's car repairs -- does nothing to cut total costs.
To decrease the costs of a repair and rescue industry, it is imperative to improve the product that enters the system. Think Toyota. A better product requires fewer and less extensive repairs. For example, a poorly made/maintained vehicle that breaks down frequently is, over time, more expensive to repair than a higher-quality/better-maintained vehicle that has fewer and less severe problems.
Put more of the bad vehicles on the roadways and you get gravy for repair shops and repair technicians (assuming you don't control wages or make service cuts).
Unless improving the product that enters the sick care system becomes the absolute, out-and-out, unquestioned, numero uno, primary reform, it will be nigh on impossible to realize the goal of cutting sick care costs.
Though lip service is paid to so-called "preventive care," the data are mixed, at best, as to any benefits that a system of preventive care can offer. Supporting the futility position is the medical profession itself, which acknowledges failure in what is arguably the most important area of disease prevention dealing with the most costly consequences:
The government can persuade people/institutions to engage in certain behaviors.
Attempts currently are underway to impose taxes on certain items in the name of improving the national health, or at least paying for sick care. This is more than likely doomed to fail. However, that is another topic worthy of its own analysis.
As to the matter of sick care reform, as it stands, it can never and will never work to accomplish its stated goals of cutting costs and increasing access. The only way to do that for a repair and rescue industry is to improve the product entering the system.
When it comes to sick care, only personal action to improve health can make a significant difference.
There is nothing in the current approach that is likely to make an iota of real difference in this regard.
Michael Applebaum is a physician and attorney practicing in Chicago, IL. His website is drapplebaum.com.