Who’s at Fault for Health Care’s Problems?

Improving health requires changing the society itself, not just individual society.

Jeff Goldsmith, “Who Is to Blame for Health Care’s Problems,” The Health Care Blog, October 28, 2015

Who’s to blame for health care’s problems – costs 3 times what they were in 1965, when Medicare made its debut, longevity lagging behind other developed nations, and now, a sudden spike in premature deaths in whites aged 45-54 ?

Unhealthy patient behavior? High physician incomes? Wasteful government spending?

The answer may be: all of the above. The answer may be twofold: 1 ) the nature of American society, with its penchant for individualism and reliance on prescription drugs, and 2) slow economic growth, creating a sense of despair among the middle-aged, who no longer feel they can achieve the American dream of living better than their parents.

Between 1999 and 2013, the Proceedings of the National Academy of Sciences reports death rates per 1000,000 people, among whites aged 45-54 in round numbers were: 420 for U.S., 325 for France, 300 for Germany, 375 for U.K., 250 for Canada, 225 for Australia, and 210 for Sweden. Yet the U.S. spends at least twice what these other nations spend.

Jeff Goldsmith, President of Health Futures, Inc, says the usual narratives explaining the culprits for this spending spree are:

• Among conservatives, The Patient. Patients they argue smoke too much, eat too much, consume too many sugary drinks, exercise too little, and rely too much on prescription and non-prescription drugs. Bad health behaviors that lead to health disease, diabetes, and lung ailments.

• Among liberals, The Physician. Physicians, they contend, have target incomes to reach, and the use the fee-for-service system to do too many tests and perform too many procedures to reach their target.
The progressive solution is to stress prevention and wellness and to replace FFS “volume” with data-based “value” outcomes, and to pay physicians accordingly. Congress has embedded this concept into value-based physician payment incentives in 2015 Sustainable Growth Rate fix.

The truth is that neither the conservative or liberal fix is wholly right or wrong. Smoking, obesity, and reliance on drugs rather than good health habits do have a negative health effect. And, in theory, prevention and wellness, decreasing and rationalizing physician ordering, and regulating cigarette, alcohol, and drug advertising improves health among society.

The reality is health spending and health results depend on both patient and physicians, but larger factors are at play. Population health is 60% determined by social-societal factors, with genetics and inheritance 5%, health behaviors 25%, and medical care 15%, playing secondary roles.

In the U.S, according to the Centers of Disease Control and Prevention, a combination of factors are at play behind the surge of deaths among the middle-aged.

These factors include: a stagnant economy which has grown an average of only 1.7% of GDP since 2000, causing a sense of despair and depression among many and an overreliance on drugs as substitute for good health habits. Since 2000, mortality rates among the 45 to 54 crowd are up 7% to 30%, suicide up 15% to 25%, and chronic liver disease 15% to 22%. This is the case particularly among whites, who have much higher rates of taking prescription pain-killers, who die in far grater numbers from overdoses and suicides.

Goldsmith maintains there is no simple solution to our health problems. Neither seeking to change patient health behavior or physician ordering patterns or pay will solve the problem. Investing more heavily in public health might and reducing the number of uninsured might, and so might taking steps to speed economic growth to lift people out of economic despair.