One day, you may find yourself at a Friday evening dinner party with a group of random acquaintances and the seemingly never ending humdrum of polite boring conversation slowly starts to overwhelm you with apathy for your fellow dining companions. You dig deep to muster the strength to sip your appletini and snack on your carmelized brussel sprouts, diligently counting the seconds until you can go home and watch reruns of CSI Miami. You then find yourself inspired with a crazy thought: Instead of acquiescing to a wasted night out, filled with uncontroversial soporific banter, you consider spicing up the evening and dare to broach the topic of Obamacare. Maybe earlier in the meal when you brought up abortion, immigration, or the Israeli-Palestinian conflict you didn’t get a robust enough response? Well talking about health insurance in the United States is certain to spark a passionate debate.
It’s really quite amazing how health insurance has become so polarizing. I mean in the end it’s about insurance. Could you imagine if someday the same level of fervent opinion spread to the car insurance market? I can see it now- Flo from Progressive burning the Geico Gecko in effigy on the White House lawn.
Are we still talking about health?
You’ll often hear a candidate at a political rally relay a “call to action” story portraying some poor young women diagnosed with a rare treatable cancer, but because she is self-employed and has no health insurance, she has to choose between not getting treatment and a lifetime of debt and bankruptcy. That sucks. In this story, it seems that having or not having insurance is the most important factor dictating an individual’s potential for health.
But’s lets consider another perspective. Imagine we inundate the country with crappy fourth tier health insurances. These insurance plans might reimburses a physician eight dollars for an hour of labor (that is a real number). For a physician with a private practice it is simply an unsustainable level of reimbursement even for the most goodhearted soul. Thus, with time, the quality of physician who would accept such insurance would decrease and decrease to the point where the only person accepting it would be some non-board certified doctor who graduated from a now defunct medical school in rural Moldova.
Now you can definitely argue that having any insurance is better than nothing, and it has even been shown to be the case, but let’s not pretend that simply providing insurance is the sole ingredient needed to get people back on the yellow brick road to the Land of Health. Insurance has the potential to open the door to a healthier life, but it needs to give access to quality care, not just reimburse some random crappy doctor’s bills.
We Think of Healthcare as an Individual Issue
Healthcare in the United States is weirdly very similar to the amazing and complex rescue of the kids that got trapped in the cave in Thailand. The rescue required thousands of people from multiple countries, millions of dollars, navy SEALS, an anesthesiologist, and some extremely talented cave divers with very unique skills. The rescue was nothing short of phenomenal. But in retrospect, wouldn’t it have been way way easier to just put a big fence in front of the cave and prevent people from going in?
That’s the American healthcare system. We have very talented individuals and prestigious institutions that treat increasingly complex disease states with evolving expensive technology. We however don’t actually promote maintainance of health in individuals in any meaningful way.
In other words as individuals we each desire access to the highly skilled cave divers and water pump systems to save us, but as a society we don’t want to put a damn fence in front of the cave.
Look to the Scandinavians for Ways to Build that Metaphorical Fence
As we continue to fiercely expend energy debating the economics, morality, and feasibility of our health insurance system, maybe we should examine the very different approach Finland has taken over the last few decades to improve their overall health?
Rampant Coronary Artery Disease
In the 1970s Finland had the highest rate of coronary artery disease in the world and it recognized that fact as a major problem. They tapped a 27 year old doctor named Dr. Pekka Puska to lead a long term pilot program in the far eastern province of North Karelia. His goal was to try and figure out why so many people in the province were dropping dead from heart attacks and find a way to fix that.
A new approach to Improving Heath
Dr Puska considered data that hinted your health and lifespan were better predicted by the population you belonged to, rather than your individual doctor or hospital. Think about that for a second- access to a specific doctor or treatment is not the most important factor at play when it comes to health, but rather the key factor is the physical and social environment of your society. He decided that instead of focusing on treating each individual in the province, he would instead focus on treating the population as a whole.
Where to start?
Around this time, it became evident in the medical literature that the more animal products and fat people ate and the more they smoked, the worse their cardiac health. The North Karelia population ate a predominantly meat based diet, used a lot of butter in their cooking, and over half the men smoked. It was pretty obvious what needed to change- the question was how to change it.
Dr Puska didn’t create a list of federal recommendations and post it for all to see. In fact, he did the opposite. He started a grassroots movement from the bottom up. He enlisted local community members from different towns to spread the word about the importance of reducing salt and animal products in their diet. They also began a comprehensive smoking cessation campaign.
The grassroots movement recruited mothers and grandmothers of the community to develop and disperse alternative healthier recipes for the traditional local foods. Berries were a healthy option and popular to eat in the area, so Dr Puska approached local dairy farms and convinced them it was economically viable for them to convert some of their pastureland from rearing livestock to growing berries. Slowly over time, the fundamental diet and lifestyle of the population slowly morphed into a healthier new normal.
Over 20 years, the rate of coronary artery disease dropped by almost 80% and lifespan went up by about six years. Think about that- those are mind blowing results. One could claim it is unclear exactly which variables actually improved health and to what degree, but it does seem that Dr Puska took unhealthy culturally ingrained habits and traditions and over time instilled new healthier social and environmental norms into a population. The result was the health of many of individuals in that population dramatically improved.
What Could We Do Today in the United States?
Let’s face it, people in the US are obese- and if you work in medicine you realize that obesity makes virtually everything more complicated to treat. Surgeries are more challenging to perform, medications harder to dose correctly, rates of complications increase. Decreasing obesity in our society would unequivically improve our health. The existence of a multibillion dollar diet industry shows us that many folks are intent to tackle their weight problems as individuals. I personally have been on and off all sorts of diets many times in my lifetime, with both success and failure. But is there a way to approach obesity from a population perspective?
What Societal Norms Could We Change?
I think a good first step would be to address the fundamentals of our diet- both what we consume and how much. Now, I’m not talking about encouraging people to eat well by simply promoting healthy foods. We do that now. I’ve seen enough depictions of food pyramids to blind me with their uselessness. Pretty much at this point, most folks have an idea of what they should be doing. But as Morpheus said to Neo in the Matrix :
We all know what we are supposed to do, but we mostly stink at actually doing it. Why? Are we all weak minded sloths? Maybe… but more likely we inhabit a cultural environment that makes the the easy choice, the unhealthy choice. What if, with time and effort, we could alter that environment?
Our Culture Dictates How We Eat
For some reason in the US, certainly compared to Europe or Asia, we have come to expect gigantic portions and unlimited refills on our sodas when we go to a restaurant. Why is this the case? Maybe someday cultural norms would dictate restaurant serve reasonably sized portions rather than unlimited salad and breadsticks. Maybe we could just not be offered a supersized french fries or not casually drink three Mountain Dews at lunch because our waiter feels it’s his job to refill our glass with reckless abandon?
Change Our Diet?
There is one wholesale change to our diet that many nutrition experts believe would have a dramatic effect on our overall health: vastly decrease the amount of meat we eat.
Now, I am by no means a vegetarian. To be completely honest, I’m often thrust into paranoid suspicion when I share a meal with leaf eaters. I always ponder if their real agenda is to indoctrinate me into their underground cult of vegetables and grains. I love to eat meat. If required, I would have no issues shooting and butchering my dinner. But in this modern world where everything is so readily available, I don’t have to kill my lunch. That is probably why I eat too much of it. People in the United States eat three times as much meat as anyone in the rest of the world. Chicken has become so commonplace, it is often simply listed as a topping. In fact, I would go so far to propose that the vast quantities of meat we consume now is a root cause of the worsening health of our society. We pump hormones into livestock and poultry to increase their quantity of edible meat. We raise them in overcrowded factories, inject them with antibiotics risking the development of resistant bacteria, and pay little attention to the ethical treatment of the animals. Cheap, relatively affordable meat, chicken, and seafood is readily available at every every meal…and we think nothing of it.
What Could Promote us to Eat Less Meat as a Society? I Have an Idea and I’m Not Sure I Like It…
We could all individually make the choice to eat less meat. That is always a choice. But is there a way to promote overall less consumption of meat by society as a whole? I can think of one likely effective way:
Drastically increase the price of the meat.
Political and cultural pressure to decrease the use hormones and antibiotics in animals and transition to the free range raising of livestock would likely have downstream effects. With the elimination of the cheaper definitely non-organic factory-like raised meat and poultry, the most likely consequence is that meat would become more expensive. I think for our society’s overall health that might actually be the best thing that could happen. Because it costs more, we would likely eat less of it and the meat available would be of better quality. Now hopefully meat would not become so expensive that ribeye becomes the new caviar, limited only to the 1% of society. It is also possible that a decrease in steak consumption would be replaced by a commensurate rise in donut binging, negating any positive health effects. However, with education and promotion of healthy eating options, it is conceivable our diets could evolve to become slightly more vegetable based. We don’t all have to become vegans and subsist off a diet of quinoa and raw beets, but maybe just a little less meat could improve our health?
Many Ways to Promote Heath
There are of course many aspects of our society other than just our diet that could be addressed with a similar strategy to improve the health of our population: physical exercise; gun safety; mental health; drug abuse. Promoting the health of our society, through lobbying government policy makers, encouraging cultural shifts, introducing educational campaigns, and aligning business priorities with health priorities could improve the health of our population outside the structure of the traditional health care system and federal government. Maybe we could sidestep the political hornet’s nest that is the American health insurance system long enough to find a way to improve the actual health of Americans?
Just don’t call it Obamacare.