Heading the Wrong Way

In the middle of political distractions that drown out most other news, the persistent bad news on American healthcare continues to roll in.  In the past few months, the following has been reported:

• Uninsured rate has increased for the second straight year, increasing by 1 million people to over 30 million
• Overall healthcare expenditure grew by 4.6% to over $3.6 trillion
• Government health expenditure increased at an even higher rate, 5.6%
• LIfe expectancy dropped for the 3rd straight year
• Annual premiums for a family exceed $20,000 for the first time

Amidst the ongoing "who pays for healthcare debate", we seem to be missing the big picture.  Who pays is part of the question; what difference does it make is a much bigger question.  Shouldn't we all be upset about healthcare that costs more and delivers less?  Shouldn't we all start challenging our politicians, our doctors and ourselves to ask different questions?

A few things to think about:

Access matters, but it isn't the whole issue
While increased access to healthcare proved to offset some mortality, there is little evidence that the expanded access of the ACA really helped make people healthier.  This is partly because of the emerging realization that a rather small portion of overall health is determined by interaction with the formal healthcare system.  Consider the following diagram:
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Only 20% of health outcomes is driven by access to and quality of clinical care.  Yet that is where our focus resides.

On the bad news front, much of this is illustrated by the reduction in life expectancy.  Ohio is a microcosm of the major effects:

...the areas of the state that have the longest life expectancy tend to be in our suburban communities, which are doing better economically. The shorter life spans are happening in some of our urban communities, certainly, shorter lifespans for African Americans and then in, also, some of our rural and Appalachian counties.

...the overdose death numbers are really driving this. But we think that it's important that we continue to focus on tobacco. Ohio has much higher rates of smoking among adults with low incomes and lower educational levels and for people with mental illness and disabilities. We also know that people who have experienced trauma are much more likely to smoke. You know, imagine, for example, a woman who has lost her son to an overdose death and is now raising her grandchildren with special needs. Quitting smoking is probably not her top priority. In fact, she might see smoking as a way to cope with the stress. So all of these issues are really connected. And we need to be doing more to help people quit and help people struggling with addictions.

Addiction, overdose and suicide are predominately issues of the young, not the old.  They are also issues that gather steam outside of the formal healthcare system and are more deeply affected by environmental, economic and educational issues.

On the good news front, some healthcare entities are recognizing this.  United Healthcare continues to expand its housing initiative, addressing housing security, one of the primary drivers of poor health.  Those enrolled in housing programs have 50% lower healthcare costs than those who do not participate.  Healthcare entities focusing on these problems are becoming more and more creative, increasing access to transportation, starting conversations about nutrition and investing in healthcare education.  

Big players in healthcare are also creating forums for innovation.  For example, HIMSS is sponsoring tech and innovation challenges around rural health and aging.  Robert Wood Johnson Foundation has also created initiatives to spur creative thought and energy around these issues.  And Accenture has gone as far as appointing a physician lead focusing on these challenges.

Government has a role to play, but likely needs partnership
The focus of the policy debate continues to be on 2 things: who has access (everyone) and who pays ("Medicare for All").  These are important questions but the prior discussion implies that solving the access and pay question may not address the cost, quality or health challenge.

A little recognized fact in the push to a government-driven system: the UK has experienced a similar decrease in life expectancy over the past 2 years.  This despite the existence of the notable National Health Service (NHS).  Causes:

• Scottish suicide rates are the highest in the EU
• Dementia is claiming more lives and is incurable
• Dementia is making the elderly more susceptible to other diseases, such as the flu
• Potential impact of funding cuts to rein in costs

These issues don't go away if the US moves to a more nationalized healthcare system.  Furthermore, innovation like that deployed in the housing sector by United Healthcare would be much harder to come by.  The head of Medicaid in New York State applied for a waiver in 2014 to pay for housing; that waiver was denied.  Since then, North Carolina has achieved such a waiver.  But, government works slowly; these waivers take years while UHC was able to deploy the program almost a decade ago.

Government will always be a major funder of healthcare.  But the building blocks of a system that works must be:

• Government funding paired with employer and individual funds
• Private deployment of funds, with risk-based incentives (and caps on funding such as exist in Medicare Advantage)
• Payer-provider partnerships that reward hospitals and physicians for efficient care
• Broader regulatory enforcement of information sharing, requiring data efficiency as a baseline requirement 
• Price transparency to support consumer decisions
• Flexibility in deploying funds to address root causes; this would mean that Food Stamps make more sense as part of the healthcare budget instead of management by the Department of Agriculture

Of course, this isn't a complete list.  But what it indicates is a need for a completely different approach and a different perspective on the way healthcare is funded and delivered.  The technological innovation that is taking place in healthcare makes more and more of this possible, but we must remove the barriers- policy, economic and perspective- that stand between us and a different outcome.