Recently we wrote that it was well past time to end the employer mandate in the Affordable Care Act. In light of some commentary, we thought it best to revisit this issue in more detail. It seems that most of the support for the employer mandate comes from a misguided understanding of why employers are currently the primary source of private health insurance. It is explicitly not because of a sense of “responsibility” to the employee, at least not any more responsibility than they feel when they pay employee wages for their work.
Here is a basic summary of how labor markets work, based on decades of very widely accepted academic research and practical experience. Employees receive compensation from their employers in return for their work product. In other words, employers aren’t running charities for their workers, but neither are workers volunteering their time at firms. Each expects something from the other. Some employee compensation comes in the form of cash wages and some in the form of fringe benefits such as health insurance, pensions, free coffee, parking, etc.Continue reading…
President Obama has spent a lot of time defending his health law, but he appears to us to be quite ill-equipped to actually talk about health. In fact, it’s the just about the only thing he doesn’t talk about. He’s talked insurance, web sites, and funneling even more money to medical care providers. He’s talked about deadlines. He’s talked about glitches. The shocking lack of official communication about what should be the central message of any drive to make Americans healthier should tell us something.
In point of fact, no American leader since John F. Kennedy has had the courage to implore us to work for our own better health. He wrote in 1961 in Sports Illustrated:
“Thus, in a very real and immediate sense, our growing softness, our increasing lack of physical fitness, is a menace to our security…if our bodies grow soft and inactive, if we fail to encourage physical development and prowess, we will undermine our capacity for thought, for work and for the use of those skills vital to an expanding and complex America. Thus, the physical fitness of our citizens is a vital prerequisite to America‘s realization of its full potential as a nation, and to the opportunity of each individual citizen to make full and fruitful use of his capacities.”
By JFK’s clear, powerful, and time-tested standard, we are a disaster. We have no leader on health. Nobody.
If the Forest Service has Smokey Bear and local law enforcement agencies have McGruff the Crime Dog, where is our fearless leader who makes doing healthy things cool, interesting, and desirable?
Doing healthy things is not cool, and until it becomes cooler than doing unhealthy things, we are delivering to ourselves and our kids a future of misery and entrapment in a medical care system that regards us and them as widgets in its revenue cycle.
Ask any kid on any playground who’s their role model for living a healthy life, who’s teaching them the value of eating smartly, exercising, and managing their stressors, and you’ll get a blank stare For example, standard medical advice is that electronic gaming is bad and is a major contributor to inactivity and declining health in our children. But, gaming is here to stay, and we don’t see how professional finger-wagging gets kids to make better choices. Who’s their enlightened leader to tell them that getting up and getting fit will make them even better gamers? Nobody. Leaders meet their followers where their “heads” are and craft messages that connect and inspire action.
Meaningful Use and Pay for Performance – two of the most talked about programs in healthcare IT over the past several years. They are both based on the premise that if you want to drive behavior change among providers and improve quality of care, you need to offer financial rewards to get results.
But what about the consumer? We have now entered a new era in healthcare where the consumer is rightfully front and center – AHIP is even calling 2014 the “Year of the Consumer.” Payers, and other population health managers, who until recently viewed consumers as claims, now want to “engage,” “motivate” and “delight” them.
The challenge, however, is that we are giving consumers more responsibility, but not making them accountable for the quality of care they provide for themselves.
As a country we have spent tens of billions of dollars on Meaningful Use incentives and Pay for Performance programs for clinicians. Providers need to demonstrate they are making the best choices for patients, being efficient and coordinating care.
They need to educate patients and give them access to information based on the belief that if patients are informed, they will take responsibility and action. Unfortunately, this seems like a “Field of Dreams” spinoff – “If we say it, they will act.”
However, that movie has a different ending. The intentions are good, but the flaw is that consumers don’t simply need more information. They need personalized guidance and support, and they need to feel like they have a financial stake in the game.
So the big question is – why aren’t we spending more time thinking about how the concepts behind “meaningful use” and “pay for performance” could be used as a way to get consumers engaged in their health? Yes, clinicians are important as they direct approximately 80 percent of the healthcare spend in our “sick-care” health system.
However, what most people do not realize is that 75 percent of healthcare costs are driven by preventable conditions like heart disease and type-2 diabetes. And while some consumers may throw up their hands and blame genetics for the majority of their health issues, it’s a fact that 50 percent of what makes us healthy is under our control – as opposed to 20 percent for genetics.
So what if we made wearable technologies such as FitBit more “meaningful” for the consumer? Instead of just tracking steps, what if consumers were financially rewarded for taking steps to improve their health (pun intended) through health premium reductions, copay waivers or even gift cards?
Consider a scenario where an individual who was identified as being pre-diabetic and then took action to prevent the onset of diabetes. What if we required that proactive person to pay less in premiums than someone who was not taking any initiative to improve their health? That would clearly be very motivating.
The Founding Fathers had one. Karl Marx had one. Bertrand Russell and Albert Einstein had one. And, now I have one: a manifesto, declaring my intent to live my life with as little interaction as possible with the US health care system by doing what the Affordable Care Act (ACA) tells me by omission I do not need to do: take responsibility for myself.
This is my Personal Affordable Care Act.
My manifesto is an algorithm for thriving in spite of the government’s naked and absurd attempt to define health as something that begins in the clinic. My goal is to make myself and my family as scarce as possible within the health care system.
The ACA is a collective solution to the mass failure of individual will. Our transformation into an information culture actually worsened the malady. We are so conditioned to success at the speed of a search engine that, like the person who aspires to retire early, but refuses to save, we’ve forgotten to manage the fundamentals.
First, that every healthy lifestyle decision you make today, from diet and exercise to outlook and mood, requires thought and an exertion of will. Even in the age of Google, volition matters, and choosing not just wisely, but strategically, is an option available to most people.
Second, despite revolutionary democratization of medical information, we still don’t do our homework. Americans visit physicians 3 times per year on average, and the number one reason for the visits is “cough.” Really? You need to go to the doctor for a cough? Unless you have a fever, chest discomfort, bloody sputum, or the cough lasts for weeks and keeps you up at night, it is almost certainly viral or related to an allergen and self-limited.
Every now and then the title of a book influences your thinking even before you read the first page.
That was the case for me with Thomas Moore’s “Care of the Soul” and with “Shadow Syndromes” by Ratley and Johnson. The titles of those two books jolted my mind into thinking about the human condition in ways I hadn’t done before and the contents of the books only echoed the thoughts the titles had provoked the instant I saw them.
This time, it wasn’t the title, “Cultivating Chi”, but the subtitle, “A Samurai Physician’s Teachings on the Way of Health“. The book was written by Kaibara Ekiken (1630-1714) in the last year of his life, and is a new translation and review by William Scott Wilson. The original version of the book was called the Yojokun.
The images of a samurai – a self-disciplined warrior, somehow both noble master and devoted servant – juxtaposed with the idea of “physician” were a novel constellation to me. I can’t say I was able to predict exactly what the book contained, but I had an idea, and found the book in many ways inspiring.
The translator, in his foreword, points out the ancient sources of Ekiken’s inspiration during his long life as a physician. Perhaps the most notable of them was “The Yellow Emperor’s Classic on Medicine”, from around 2500 B.C., which Ekiken himself lamented people weren’t reading in the original Chinese in the early 1700′s, but in Japanese translation. One of his favorite quotes was:
“Listen, treating a disease that has already developed, or trying to bring order to disruptions that have already begun, is like digging a well after you’ve become thirsty, or making weapons after the battle is over. Wouldn’t it already be too late?”
Ekiken’s own words, in 1714, really describe Disease Prevention the way we now see it:
“The first principle of the Way of Nurturing Life is avoiding overexposure to things that can damage your body. These can be divided into two categories: inner desires and negative external influences.
Inner desires encompass the desires for food, drink, sex, sleep, and excessive talking as well as the desires of the seven emotions – joy, anger, anxiety, yearning, sorrow, fear and astonishment. (I see in this a reference toarchetypal or somatic medicine.)
The negative external influences comprise the four dispositions of Nature: wind, cold, heat and humidity.
If you restrain the inner desires, they will diminish.
If you are aware of the negative external influences and their effects, you can keep them at bay.
Following both of these rules of thumb, you will avoid damaging your health, be free from disease, and be able to maintain and even increase your natural life span.”
On the topic of Restraint, the Yellow Emperor text states:
In the remote past, those who understood the Way followed the patterns of yin and yang, harmonized these with nurturing practices, put limits on their eating and drinking, and did not recklessly overexert themselves. Thus, body and spirit interacted well, they lived out their naturally given years, and only left this world after a hundred years or more. Continue reading…
I was a chubby kid, which brought with it all manner of slights, both real and imagined. My predicament was worsened because I came from an immigrant family, and my father was tormented by unrelenting and untreated bipolar disease. When he was lucid, however, he taught essential lessons that neither he nor I knew at the time would become my life’s cornerstone: don’t trust the professions too much; advance your own cause through limitless learning; and, use exercise — all forms of it — as an irreplaceable lever for personal betterment. My dad may have been out of it more often than not, but he swam, did calisthenics, played tennis, and boxed, and he walked vigorously right up until the end of his life. I saw, I learned, I did (and still do).
Imagine, then, my chagrin at how the Affordable Care Act (ACA) effectively shears away the concept of personal responsibility and mastery of lifelong wellness skills from the pursuit of actual health. It was a huge missed opportunity to teach Americans about what’s first in the line of responsibility for good health.
Instead, the ACA’s philosophical foundation ignores the power that individuals have to impact their personal health trajectory, and it compels Americans to accept lifelong roles as patients in a system that many of them not only don’t want any part of but that they distrust and don’t understand. It is exactly the opposite result that something called “health” reform should have produced.
I’ve been thinking about how to write this story for a long time. Should it be a book? A blog? A self-help guide? Ever since I realized I’d lost 60 pounds over the course of a year and a half, I knew I wanted to find a way to talk about it, and maybe help others. This is my first public attempt.
A note about the rounding of my roundness: My peak weight, shortly after I began weighing myself in 2010, was 242 lbs. My lowest weight since I started weighing myself has been 183.2 lbs — right in line with where I should be, at 6’3″ tall. I’m sure that I weighed more than 242 lbs. at peak, but frankly, I don’t care that I don’t have the data to account for those last 1.2 lbs.
Adam Davidson’s New York Times Magazine story, “How Economics Can Help You Lose Weight,” helped organize my thinking about how to finally write this. In his story, Adam explains that the rigid protocol his doctor puts him through acts as a kind of economic incentive for him to stay on the diet. I’m highly skeptical that the special liquid meals he can only buy directly through his dietician will help him keep off the weight. I tried all sorts of diets in the many years that I was overweight and though I never tried the Adam’s solution, it doesn’t sound like a recipe for long term success. At least twice, I lost weight and then gained it all, and more, back. (Meta note: I feel terrible writing that. Adam, I wish you the best. Maybe something you read here will help you keep off the weight you have already lost, and congratulations on that difficult achievement.)
Now that I’ve managed to make weight loss sound simple, and sound smug about my success (I’ve stayed within the 183-192-pound range for more than two years now), what’s my big secret? It’s data. Just like I said in the headline, I keep a Google Doc spreadsheet in which I’ve religiously logged my weight every morning for the last three-plus years, starting on January 1, 2010, when I knew I had to do something about my borderline obesity.
Whenever I think about health care reform, I am reminded of the song from the film Marry Poppins that goes “Just a spoonful of sugar helps the medicine go down.” You would think from the way Conservatives are always blathering on about the moral fiber of America breaking down because no one takes responsibility for their actions anymore, they could use a spoon full of fiber rather than sugar. They warn about the dangers of the “nanny state,” and “socialist ideas,” and deride progressives for “being enemies of success.” At the end of the day, so the conservatives say, it’s a matter of personal responsibility and personal choice.
You know what? I couldn’t agree more. It really comes down to the choice between a thick glass of Metamucil or a smooth glass of sweet tea. Which would you prefer?
Having everyone take responsibility for their own health care started as a Republican idea. And by and large, Americans agree. But a new poll out this week showed many Americans still have a long way to go in understanding what the new healthcare actually does, particularly on the “individual mandate” portion and in the face of continued right-wing attacks on health reform.
Simply stated, the new health care law makes sure everyone takes charge of their own care and gets affordable insurance, because when people without it get sick, the costs get passed down to the rest of us. For health insurance to work, it’s necessary to include people who are healthy to help pay for those are sick. Under the ACA, you can keep the coverage you have. Or, if you don’t like your plan, or don’t have one, you can pick an affordable insurance option to take personal responsibility for yourself and your family.
A reader writes to ask: What about personal responsibility? “I see no movement afoot to require the public to accept or meet norms of behavior that would reduce the need for medical treatment—smoking, excess drinking, use of drugs, over weight, etc. What ever happened to ‘You reap what you sow’?”
Good question. I answered:
Thanks for writing. This is a common concern. It’s often expressed something like, “Why are we paying for all this healthcare for people who won’t take care of themselves?” This seems, at first blush, an obvious question with an obvious answer. After all, as I constantly point out in what you read, vast amounts of healthcare dollars are spent to correct what we might call “self-inflicted lifestyle damage.” Why should the rest of us pay for that? Where is the responsibility?
On inspection, the question is more complex and the answer is not so obvious. Let me try to parse it out. I can think of four related aspects of the question.
1. Their health affects ours. My wife and I had a lovely dinner at a very nice French restaurant on the waterfront here in Sausalito last night. The staff was all French, with those endearing accents. The busboy who set our table, poured the water, took away dirty plates and all that, was Mexican. I talked with him a bit in Spanish about the nice weather. I have no way of knowing his immigration status. Now, if I had my ‘druthers, just as a customer, would I rather that he have good access to healthcare and healthcare advice, be up on his flu vaccinations, be aware of the importance of washing his hands frequently, or would I rather he be a seething mass of communicable disease, compounded by ignorance?
It is not a secret that I dislike tobacco companies. Intensely. I do not see the point of allowing them to sell a product whose value is all in the negative. I am appalled that we are looking for expensive ways to diminish lung cancer mortality before considering a complete ban on this disease promotion apparatus. Yet this story in the LA Times got my goat. Briefly, a woman who has smoked for years and has had smoking-related obstructive lung disease since 1989 decided to sue tobacco companies after developing lung cancer in 2003. The suit has been making the rounds in various levels of courts, since the defendants asserted that she had exceeded the 2-year statute of limitations following the onset of her smoking-caused disease, referring to the 1989 COPD diagnosis. However, the California State Supreme Court has ruled that she can still sue the manufacturers, since she filed her suit within two years of the lung cancer diagnosis. So, why am I bothered?
Well, here is the thing: once you develop lung disease, followed by periodontal disease, as this woman did, had she really remained unaware that cigarettes are bad? That they cause problems? Is it really possible to live in our world and NOT be aware that tobacco kills? And if she was aware and continued to smoke, whose responsibility is it that she developed lung cancer, hers or the manufacturer’s? Well, you say, but the tobacco companies are unethical and lied about making cigarettes more addictive by adding undisclosed ingredients. So, how are we, the consumers, to know? Well, this is pretty simple: We have free will, don’t we? And if you have the free will, you have to exercise some will power, no? Is this not what the human condition is all about? Continue reading…