Monday, May 9, 2016
Health care: of United, and citizens
The disturbing news item of the past week—assuming we discount the increasingly routine reports of terrorist bombings, boats packed with desperate migrants capsizing, the global temperature relentlessly rising, and Russian military bombast—is that the nation's largest health insurer, United Health Care, is withdrawing its involvement in the state exchanges of the Affordable Care Act (ACA), aka Obamacare. United is opting out due to the high costs of participation, and their departure effectively passes those costs along to other insurers, and of course, to us, the insured. The citizens in states where United was an important option will now have fewer options, and likely face higher premiums and/or deductibles.
Detractors of the ACA perhaps see this as something of a vindication, but the details behind this story suggest that is very misguided. The high costs to United of involvement in Obamacare are really all about sick people getting care they actually need. The very point of the Affordable Care Act is to bring coverage, and thus access to care, to those formerly left out entirely. It is, apparently, working.
The result is that people for whom health insurance was formerly out of reach now have a way into the system, for themselves, and the costly baggage of their neglected pathology.
That is the prevailing speculation about United's financial woes. The population gaining access via the ACA tends to be poorer, and sicker. Since this is a group that traditionally did not have health insurance, they have, in many instances, foregone care whenever possible. Any insurer that is the first point of entry for this group will encounter the pent-up need they have borne, and the costs attached to addressing it.
We can speak in terms of baggage, pathology, and costs if we approach this topic from the perspective of United executives, or financial analysts. But I am an unapologetic humanist, and I much prefer to use alternative language, and put human faces to this. We are talking about suffering and stoicism; forbearance, and foreshortened lives. We are talking about people who neglect their health, and maybe even that of those they love, because they can't afford to do otherwise.
I have at times seen the faces of those caught up in this narrative. In one terribly tragic case, a member of a cousin's family—and thus, arguably, a distant member of my own—died at 34 of melanoma. Let's call him John.
He first noticed the abnormality on his skin when in-between jobs, and thus, without health insurance. In his early 30s, he didn't have cash reserves to pay out of pocket for medical care. So, he waited until once again employed, and once again insured, to have that skin lesion assessed. The wait proved lethal. During those months, the melanoma had metastasized. A system of portable health care coverage that transcended employment would certainly have save the life of this young man, only recently married.
Then there was the case, many years ago, of a young mother—let's call her Jane—I met in a homeless shelter in New Haven. She, too, was in her early 30s, with a 4-year-old daughter at her side, when I saw her for an on-site “check-up.” She was severely limited by shortness of breath and heart failure, and would never be otherwise.
It need not have been so. A couple of years prior, she had developed a pain in her calf. I no longer recall the exact circumstances. The pain started out mild, but progressed, and became fairly severe. It was like nothing she had experienced before. Any of us, with a severe, unexplained pain in our leg, would have gone to see a doctor. She did not, because she had no insurance, and no doctor. A doctor visit for her meant finding something to do with her daughter while she spent many hours waiting to be seen in the emergency department. She tried her best to avoid that, by toughing it out.
That proved a tragic mistake. The pain in her leg was a blood clot. As they inevitably due when neglected, the clot broke, sending fragments into her lungs. Blockages in her lung were life threatening, and resulted in a 911 call, a trip to the hospital by ambulance, emergency care, and a stay in the ICU. The inconveniences the patient hoped to avoid were, obviously, massively amplified. The damage to her heart and lungs was permanent, so her health, and thus her life, were ruined. And, the costs to the system were vastly higher than earlier care of the leg would have been in the first place. Everyone lost.
John and Jane, and the millions like them, are the rebuke to those who see United's reticence as the basis for an “I told you so” about Obamacare. United doesn't like the costs, but it's not as if those costs weren't with us all along. People like John and Jane have been paying them, and generally without the option United has of saying: no thanks. They have paid with years lost from their lives, and life lost from their years.
One potential solution to this, routinely brandished heresy here in the U.S., is a single payer system. Ironically, many of those who see this as radical, heretical, and anathema are quite adamant about the protection of Medicare, which is, of course, a single payer system for those 65 and older. If Medicare worked like the private system, then perhaps it would cite the high costs of care in Florida, where a lot of older (and all too often sick) people settle—and withdraw from the state. If we don't like the idea of our older relatives in Florida being abandoned by their health insurer, perhaps we might choose to see the United disengagement from the ACA through that same lens. Maybe health insurance really should be a universal right, not a business decision.
The other implication is of the “I have a hammer, and so I see nails“ variety, as president of the American College of Lifestyle Medicine. Eating more optimally, being active, avoiding tobacco, and hitting a few other highlights of living well has the potential to eliminate some 80% of all chronic disease: heart disease, cancer, stroke, dementia, and diabetes. From my perspective, the human bounty of this—more years in life, more life in years—more than amply makes the case. For those inclined to other currencies, however, we may note that the financial advantages would be astronomical.
I favor universal access to our so-called “health care” system, and thus, something more like Medicare for all. Colleagues and I have published a detailed model that differentiates the elements of care that should be a human right, from those that are reasonably discretionary. I see no heresy in the mix, but if others do, well, vive la difference.
The greater opportunity, however, is not limited to how we cover the costs of caring for pathology that needn't have developed in the first place 8 times in 10. It is in preventing it. That requires turning what we have long known about lifestyle as medicine into what we do. It requires a cultural and political commitment to actual “health” care, rather than just after-the-fact disease care. Bluntly, it requires the honesty to acknowledge that a culture lamenting the high and rising prevalence of diabetes in its youth, while continuing to peddle at every opportunity soda, toaster pastries, and multi-colored marshmallows as part of a complete breakfast reeks of hypocrisy.
As for the status quo, United is a business, and has the option of renouncing its high costs. The people paying for business as usual with their lives do not.
David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
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