Americans spend more on healthcare than any other industrialized nation. With the election looming closer, it’s almost impossible to pay attention to current events without hearing it every single minute of every single day. Unfortunately, we never hear the two corollaries. 1) The quality of our medical interventions and management is superior in every single way. 2) The United States leads the world in living as unhealthily as possible. If our outcomes are worse, look to the latter. If our costs are higher, look to both.

Every day I hear pundit after talking head waxing poetic about what we can do to avert the healthcare crisis. Doctors get paid too much (really, how about you suspend your life, goals, and dreams until you’re AT LEAST 28 before you start doing what you’ve wanted to do all your life, with mountains of debt, paperwork, regulation, and other little nuisances looming over your head?). HMOs make too much money (true, in no small part to government regulation). Drug companies are after profits (well, yeah. That’s what corporations do. Physicians can accept some blame here for flawed studies, ever more pervasive medication guidelines, and NBT-ism*).

What I never hear from any of the people who supposedly have the answer to this, is the importance of the American public taking their health into their own hands. The simple truth is that the vast majority of the day-to-day costs of healthcare are rooted in our own lifestyles. Diabetes, heart disease, depression, anxiety, low back pain, arthritis, all of these things are if not 100% preventable, at least largely within our control. What we cannot prevent, we can alleviate and manage by living our lives as best as we can.

The philosophical model of the individual under which the majority of the public seems to operate under is that of a powerless pawn in the grip of fate. Diseases, conditions, and injuries happen to people. They aren’t expected, they aren’t incurred, and god forbid anyone even imply that how you live had anything to do with your current predicament.

It’s not surprising that this is what they want in healthcare coverage. Pay a yearly fee, go to the doctor, get tests, get medications, get interventions, without any further expenditure of time, effort, or money. They want as little an active role as possible in their own health care. This is not insurance folks, this is health maintenance.

What the public seems to want is for doctors, pharmaceutical companies, and the healthcare industry to manage every aspect of their health. And they seem shocked when as their health deteriorates and their demands grow greater, that costs grow.

I came to medical school with a different model in mind, a model that’s only been reinforced as my third year draws to a close. Something not so far off from what Edison voiced when he said that “The doctor of the future will give no medicine, but will interest her or his patients in the care of the human frame, in a proper diet, and in the cause and prevention of disease.” As a 10 year sufferer of Reflex Sympathetic Dystrophy and as someone who spends no small amount of time counseling informally, there is no value I hold higher than the Agency of the individual.

Whether the ailment be physical or psychological, the most important thing to me is to promote the individual’s sense of free will, their belief that they can effect a change in their own destiny by their own hand. In my one year on the wards, I’ve seen heart disease in 30 year olds with no family history, 70 year olds as thin as a rail telling me that their children have diabetes but they have no health problems themselves, and I’ve seen more sedentary, obese, low muscle-mass people with disability for low back pain than I can count. And I’m not even going to mention the rate of COPD in the great state of Oklahoma. This is not the picture of a world in which bad things occasionally happen to people. This is what it looks like when individuals fail to take the maintenance of their own health as seriously as they do Oprah and SportsCenter. This is the failure of the individual to recognize and accept responsibility for their own agency.

The nature of healthcare has changed dramatically in the past few decades, from one in which visits to the doctor were infrequent, pillboxes were tiny one-chambered affairs, and people with chronic conditions were few and overwhelmingly elderly, to one in which our doctors are on speed dial, personal organizers have sections for medication lists, and healthcare utilization has become a part of our everyday lives.

The only way out of this mess as I see it is to stop being Enablers. As the American public eats, sits, and poisons itself into oblivion, instead of allowing them to continue to ask “who’s going to clean up this mess?”, we need to ask them who made the mess in the first place. We need to follow Edison’s advice and return the patient to their position of power. We must act as advisers and educators first, stepping in to manage illness, trauma, and chronic conditions only as they lack the capacity and power to. But patient agency goes far beyond just taking an active role in one’s own health, but also in the decision-making process of paying for medical care. From what level of coverage to who they choose to carry it out. Anything else would be to only further the deteriorating healthcare situation.

One of my philosophical influences, Garret Hardin, wrote about The Tragedy of the Commons. In such a scenario, some see the benefits, while everyone pays the costs. In such a scenario, we are ill-motivated to curtail the costs we incur as we never feel them directly. Such is the situation of our current healthcare structure. Even though we continue to bemoan the increase in out of pocket expenses, premiums, and denial of coverage, the direct costs of our own personal health situations are still very much spread out, and even when not, can be heavily concealed from us.

Premiums have risen dramatically, as my meager pocketbook can attest to, and while much of this is due to graft and greed on the part of HMOs, a good deal of this is due to the fact that the average person and thus the average health insurance enrollee incurs greater costs. Frequent PCP visits for minor ailments, antidepressants, anti-reflux medication, BP medication, diabetes medication, pain intervention, specialist visits. All of these things have seen dramatically increased utilization over the years. More people utilizing more healthcare, of course insurance will go up. And yet nary a mention of this I’ve seen on the news our out of the mouths of politicians.

In such a situation, it would behoove the individual to have the ability to choose their level of coverage and who their provider would be. Two of the greatest disservices that have been done to health care consumers was the coupling of employment to health insurance, and the comprehensive health insurances mandates currently inundating the country. Your employer doesn’t ‘pay for’ your health insurance. You do. ‘Employer contribution’ for social security, unemployment, and healthcare are actually part of your pay, you just never take it home. But when you relinquish a part of your income to your employer for HMO purchasing, you run into an ugly little problem: Your employer may be legally bound to use your money to buy ‘comprehensive’ health insurance by law, but that only means they will try to find the cheapest coverage that satisfies legal requirements regardless of how well it actually takes care of you. This is pretty well evidenced by the fact that although I’m a medical student spending all day in the finest academic hospital in my state, we are offered the most pathetic health insurance known to man. Which is why I don’t purchase it.

More importantly, as mentioned earlier, when you buy health insurance, you are pooled with all the other people also enrolled at a similar level of coverage. What you pay isn’t based on what you spend or are likely to spend but what the group as a whole does. As this group continues to profligately waste away their health, substituting expensive medication and specialist visits for better living, you are forced to share costs with them. For some people, this is pretty sensible. Those with a family history of chronic conditions, those with young families, and those who simply don’t care to take their health into their own hands are pretty well served by the traditional model of health insurance. Yep the premiums are pretty high, but so is your healthcare utilization. As an example, there’s a guy I know in his late 40s who has well-managed diabetes, taking metformin, niacin, omacor, and one other diabetes drug. His family’s health insurance comes to about 7200 a year, but when you subtract all the expenditure for diabetes that would’ve otherwise come out of pocket, the balance is only about 1200 a year. That covers routine visits for his wife and kids, emergencies, and any further expenses he or they might incur. Including his wife’s recent expensive cervical fusion operation. Which is actually pretty reasonable when you think about it.

Contrast that with me a young 24 year old with no wife, no kids, and conditions beyond the RSD. I get an MRI every year to watch for further deterioration of a very ugly symptomatic herniated T8/T9 disc and some less ugly less symptomatic cervical discs (thanks to the RSD), the occasional specialist visit when there’s an issue I’m not able to manage on my own in the weight room, and 32 dollars worth of mobic and cyclobenzaprine a year (a lot of which ends up thrown away). Even with my condition, my expenditures are never more than 1500 dollars a year. How much sense would it make for me to enroll in the 3200 dollar school health plan that doesn’t cover the most important part (MRI) anyway? Not a whole heck of a lot when I could pay the much more modest sum for critical care insurance and drop the occasional dollar in a Health Savings Account. Especially given that, in the event that I do develop diabetes or heart disease (unlikely given my nonfasting total cholesterol of 150, perfect FBG, and 15 hrs a week in the gym) the critical care insurance will pay me a rather large lump sum right then and there.

The truth is that when you buy into comprehensive health insurance, you buy into a total package that involves healthcare as a part of your lifestyle, rather than something to be used in an emergency or disastrous situation. This is especially true in today’s environment as more and more people develop ‘chronic conditions’ through their own way of life. Those who choose to live right and live well simply do not need this level of coverage. Or at the very least should be able to take advantage of pricing contingent upon how they manage the risk factors under their control.

As Americans, we should be able to choose the level of coverage we desire in keeping with the way we live our lives and a rational assessment of our risks. We do so with our cars, choosing high deductible liability insurance on beaters and low deductible comprehensive insurance for our BMWs. Why not with our bodies? My car insurance offers a 10% discount for defensive driving classes, and lowers my rate every year I don’t have a speeding ticket. Why should I not be offered the option of cheaper health insurance that acknowledges my efforts with a discount for eating right and going to the gym, or that would first require I shed my omental fat before going on medication for mildly elevated blood pressure, or eat better and exercise more for low HDL/high LDL? That’s what insurance is all about? Assessment and reward for risk reduction.

Taking it a bit further, let’s say a 28 year old walks into your office at about 220lbs. He used to be a linebacker in high school and tried out for college ball but didn’t want to deal with the demands of daily practice. Now his idea of physical activity is keeping up with his alma mater on ESPN. Routine health visit reveals mildly elevated LDL, mildly decreased HDL, BP at 148/90 (x3, whatever, leave me alone), complaints of GERD, and mild somatic symptoms of depression suspicious for sleep apnea. Now, ’standard of care’ for this guy would be a low dose statin, a diuretic or maybe an ACEi/HCTZ combo, PPi, and CPAP and/or sleep study. That’s a fair amount of intervention right there. Now, I know that we give lip service to lifestyle and prevention, and he’d leave with a stack of pamphlets along with his scrips in real life, but what if we put our money where our moth was? What if we said “tell you what, I’ll schedule you to talk with a nutritionist, who can beat into your head the importance of essential fatty acids, reduced simple sugar intake, high quality protein intake, breakfast, and 4-6 smaller portioned meals a day. Then you can meet with a CSCS (certified strength and conditioning specialist) for another hour, who will explain to you how to jump on the stairstepper for 30 minutes 4 times a week on the ‘hill’ or ’strength’ or ‘fat burner’ program, and supplement that with weight training. You can come back in three months having lost 15 lbs and I’ll re-evaluate you then.” He comes back in three months with his BP problems remarkably having disappeared and his lipid profile drastically improved (although his LDL could use a little more work), and his sleep troubles dramatically alleviated. We start him on a PPi. Now let’s say he doesn’t take care of the factors in his control and comes back. “We’ll treat you. That’s what we do. But if you’re not going to put the time and effort into taking care of your body, you can pay a bit more of the costs of your medication.” Now, let’s say he DOES put in some effort, loses some weight, and seems to be committed to a healthy lifestyle, but the problems continue. “You’ve done your part. You should be proud of yourself. And I know it didn’t help with all of the problems you have, but believe me, it will pay dividends down the road. Here’s your scrips. It’s a pleasure having patients like you.”

Now let’s say a mildly overweight female in her mid forties comes into your office complaining of low back pain, fatigue, and has a webmd article with all her symptoms of fibromyalgia helpfully highlighted. Her obese husband’s come along because his knees ache something fierce these days. You notice that she stands ‘bonily’ (no official medical terminology for it), slouching and seeming to carry all of her weight on her bones and joints, not in her muscles. Guess what? Off they go to the nutrionist and exercise physiologist. Maybe a physical therapist as well in her case. And given the high comorbidity of CFS and fibromyalgia with depression, it might not be such a bad idea to have her see a psychiatrist for further evaluation. Send them off with some mobic and wish them the best of luck. See them back in three months before you pull out your list of orthopedists and pain specialists you refer to. Fibromyalgia, low back pain, and arthritis are expensive conditions and largely have to do with deconditioning of our postural and girdle muscles. Getting our muscles back in working order is the most effective intervention we can make with regard to these increasingly prevalent ailments. Depending on how much damage has already been done, we may not be able to avoid more costly and invasive procedures, but we may be able to delay them.

Rational decision-making is based on freedom of information and accurate assessment of costs and benefits. The current healthcare paradigm in which the individual costs of aspects of healthcare (actual cost of healthcare premiums–not just personal contribution, true cost of drugs, PCP visits, specialist visits, and procedures) are concealed from them and in which they are not allowed much choice in the degree of coverage they want. The healthcare equation is one of time, effort, and money. Choosing the level of coverage you would like needs to reflect your assessment of personal risk, as well as the degree of time and effort (and a little money), you are willing to invest in your own health. The more time and effort you are willing to invest in your own health, the less money you should have to pay for your healthcare coverage and co-pays. Conversely, the less you are willing to invest in yourself as the agent of your own health, the more you have to be willing to invest in the healthcare delivery system.

The true crisis in healthcare from where I’m standing isn’t the increasing load of diseases and conditions in our population, nor is it the increasing costs of healthcare. At the root of both of these things is the dereliction of duty to self that patient, doctor, industry, and government have been party to. I’ve said before that my goal as a physician is to be useless. I really detest preventable chronic disease. And I want to live in a world where as few of my patients have them as possible. I want to help my patients do everything in their own power to stay healthy, intervening only when it becomes necessary. The current rhetoric about healthcare, and the current structure of healthcare coverage and payment, is such that it only serves to reinforce the alternative view, one in which bad health is something that happens to people, rather than something we can in large part prevent and alleviate on our own. We must make lifestyle management a part of the healthcare cost equation. And we must allow patients to reap the benefits or bear the costs (at least in part) of their own discretions. Insurance is about taking care of the factors that are out of our control. This is why the concept of insurance was developed thousands of years ago and the concept that health insurance especially needs to return to. If anything is to be done about the healthcare problems facing us today, it must be done by returning to a patient-centered focus. A focus in which the American public is made the arbiter of its own destiny.

*NBTism - Next Big Thing Ism. Using a new drug just because it’s new. Even if older drugs in the class are just as effective with little or no increased incidence of ADRs. See PPIs, BP medication, antibiotics, and DM2 drugs.