Who is Responsible For the Health Crisis in America?

A baby born in the U.S. in 2004 will live an average of 77.9 years. That life expectancy ranks 42d in the world, down from 11th twenty years earlier.

- Source: Census Bureau and National Center for Health Statistics

BLAME-STORMING THE HEALTH CRISIS

Who is responsible for the health crisis in America? Is it the government? The state of the economy? Parents? Schools? What about you and me? Restaurants? Grocery stores? Or is it our busy schedules? How about those get-togethers and parties you attend? Maybe the presented food choices are to blame. Yes! "Blame." That is the word I was looking for! We are looking for someone or some institution to blame for our health crisis.

IS THERE A GOVERNMENT CONSPIRACY?

Is there a government conspiracy? If so, just who are the conspirators? Let us get one thing straight. You and I do not need anyone's help in creating a health crisis. There is a reason for this. You and I are the greatest conspirators of our own lives. We have received more than enough information to let us know what to do to enhance our health and yet we, in many cases, do not act and make the changes. I think that clarifies the conspiracy theory in a nutshell. When I speak of this health crisis, I am not talking about medical insurance or medical costs or treatment. True, this is an important issue. However, this issue only touches on the surface of the problem. How we think, eat and live is the real cause. So who or what is responsible? Do you have an idea? Who is the villain or culprit?

YOU ARE RESPONSIBLE FOR YOUR HEALTH

You are personally responsible for all the decisions you make. Do not blame any institution or anyone else for your poor choices that lead to disease, illness and poor health.

WHY AMERICANS RANK LOW ON LONGEVITY

What has caused America to fall so far behind the statistics on longevity in the world? The ranking went from 11th to 42d. Americans do live longer, but not as long as 41 other countries, according to National Center on Health Statistics. Why is one of the richest countries in the world not able to keep up with other countries? Some say it is because the United States has no universal health care. I do not see that as the primary reason since we have never had universal health care. Here is what I think are some of the primary reasons for this trend:

Adults in the United States have one of the highest obesity rates in the world. One third of U.S. adults 20 years and older are obese and about two thirds are overweight, according to the National Center for Health Statistics.
Americans are extremely sedentary in their lifestyles.
Americans do not exercise at all or very little.
Americans eat too much and they eat too much processed foods, sugar and fat.
As long as the health care debate is limited to insurance, the health of Americans will not improve.

SAM MADE ME DO IT

Kids sometimes will do the craziest things. Once upon a time, there were two brothers. We will call them Sam and Jake. As school-aged brothers, Sam challenged Jake to climb a tree, and so he does. Then Jake is challenged, on a dare, to go farther out on a long, thin branch of the tree. He gets about half way out before the limb breaks, and he comes falling to the earth with a thump. Jake broke his nose and got some cuts and bruises. Both kids report to their mother and of course Mom asks Jake, "How did this happen?" Jake responds, "Sam made me do it!"

There are many complaints I hear about all that enticing processed food in the grocery stores. There are remarks about the special challenge of eating out: The portion sizes are too big, and there are all those irresistible, unhealthy "choices" available. I see no difference between Jake's response and these complaining adults' reactions to their plight - or, should I say, dilemma. Jake said, "Sam made me do it." Translation: Sam is responsible for Jake's poor decision to go out on a limb. That is nonsense. Jake is responsible for his own decision to go out on a limb. We adults are too frequently "going out on a limb" with our health by making poor choices while laying the blame on external circumstances or institutions -- whether commercial, social, or governmental. Cease fire with such thoughts of blaming external circumstances or other people. Take charge. Be accountable for your own actions.

INSTITUTIONAL RESPONSIBILITY

Are our institutions off the hook when it becomes to responsibility? No, they are not. I use the term "institution" in a broad sense, to include the following:

Federal, state and local governments
Political parties and politicians
Teachers and school boards
Physicians, dentists, nurses
Journalists, press and media
CEO's and corporate shareholders
Restaurateurs, marketers
School cafeterias
Workplace cafeterias
Clergy, little league coaches
Parents and caregivers
Law enforcement officers, parole officers
Military leaders (from the squad leader upward)

INSTITUTIONS ARE RESPONSIBLE TO LEAD BY EXAMPLE

What kind of leadership responsibility do institutions have when it comes to healthy eating and exercise? Institutions, as well as all leaders, have a heightened level of responsibility beyond rules and regulations of the organization. Our institutions have the special responsibility to "walk the talk," clarify the goals of health and fitness, and assume a more visionary role to set and implement standards for a solution to our health crisis. Our institutions are morally obligated to set the example by living by the higher standard required of them as leaders. This can be accomplished through legislation, executive orders and both internal and public policy making. Our institutions need to deal with the problem directly and use their special influence to save lives and prevent suffering.

HEALTH INSURANCE DOES NOT EQUATE TO A HEALTHY LIFESTYLE

Health insurance will not accomplish this. Are you looking for true medical insurance? Make your premium payments in the form of living a healthy lifestyle void of dependence on a home pharmacy of medications. Most of our medications are prescribed because of our lifestyles, not because we simply got sick. I am talking about the overwhelming rule and not the exception.

There are exceptional cases where, despite a healthy lifestyle, serious disease or illness happens. Would you cease to drive a car simply because someone had an automobile accident? In addition, you certainly should not cease to lead a healthy lifestyle just because someone you know lived to be 100 years old as a smoker. That would be a fatal error in thinking. It is just this type of thinking that is killing and maiming Americans. Ban this type of thinking from your mind.

Take the educational institutions for America's young people. Schools are primarily focused on delivering on educating our youth with an approved curriculum. Schools need to go beyond mere curriculum, to consider the whole child, setting improved fitness and healthy eating as a priority. Fitness and healthy eating should be a part of the curriculum, as they play a major role in the development of a child.

TEACHERS ARE ROLE MODELS

Teachers are role models and leaders when it comes to eating and exercise habits and how they portray their attitudes about fitness and health in school. John Maxwell defines leadership as "influence - nothing more, nothing less." Moving beyond the position of the teacher to assessing the ability of the teacher to influence others as a leader is essential. This refers to those who would consider themselves followers, and those outside that circle.

Leadership builds character, because without maintaining integrity and trustworthiness, the capability to positively influence will disappear. There are many other definitions of leadership. They all point to a leader having influence on others and providing to them the guidance and direction necessary to envision a long-term view of the future.

POINT OUR CHILDREN IN THE RIGHT DIRECTION

Policy is made from the top down through legislation, executive order, mission and policy statements. Where there is a void in such top-down leadership, the initiative must begin from the ground up. Educational institutions by virtue of their access to vast blocks of our children's time, have a unique responsibility to go beyond mere curriculum to consider the whole child. By offering and stressing healthier choices, they are setting precedent for the rest of that child's life.

Early in America's pioneer history, schoolteachers were expected to be morally beyond reproach in every detail of their own lifestyle. This reflected how those communities wanted to influence their children's future and the future of the country as a whole. Today's America likewise needs today's schoolteachers to be wholeheartedly health conscious for the same reason. Our future depends on it.

That is not to say that all schoolteachers should be fashion-model thin or good-looking or in any way shaped by the media's image. An overweight teacher who is working to improve her fitness would be preferable over the Size 4 who is proud to eat candy bars and drink sodas in front of her pupils. Institutions are role models in all that they say and do or do not say or do. Their policies and actions set the standards.

WE ARE KILLING OUR CHILDREN

Look at some statistics on childhood obesity in America. About 15 percent of children and adolescents ages 6-19 years are seriously overweight. The percentage of children and adolescents who are defined as overweight has nearly tripled since the early 1970s.

Over 10 percent of preschool children between ages of two and five are overweight.
Another 15 percent of children and teens ages 6-19 are considered at risk of becoming overweight.
Researchers found that lowered self-esteem was associated with being overweight in girls as young as five.
One in five children in the U.S. is overweight.
Children ages 10-13 who are obese are expected to have a 70% likelihood of suffering from obesity as adults.

Centers for Disease Control and Prevention's (CDC), 1999-2000

National Health and Nutrition Examination Survey (NHANES)

CHILDHOOD OBESITY ONLY AN INDICATOR AND NOT THE REAL PROBLEM

Childhood obesity is only the indicator of an underlying problem of a sedentary lifestyle and unhealthy eating habits. Address these underlying issues, and childhood obesity will be significantly reduced.

SCHOOLS, TEACHERS AND PARENTS HAVE A HEIGHTENED LEVEL OF RESPONSIBILITY

Our schools, teachers and parents have a heightened level of leadership responsibility to address the statistics that are just a few of many indicators of the direction of the state of health of our children. Once these children become adults, they, too, will pass on their lifestyles to their children and will in all likelihood perpetuate poor eating and exercise habits. The consequences will manifest themselves as learning disabilities, increased crime, and socioeconomic problems which our children's generation cannot afford to inherit.

THE MOTHER OF ALL INSTITUTIONAL EXCUSES

What is the number one excuse institutions use for not doing more to fight the poor state of health of Americans?

Answer: It is each individual's own decision as to how he or she wants to live, how he or she wants to eat and exercise or not. This is the mother of all institutional excuses. An institution using this excuse relinquishes its leadership responsibility as a visionary to lead and guide by example and exercise that institutional influence it possesses. The institutions need to ask the visionary question of what can they do to influence, guide and inspire each individual to make healthy lifestyle choices.

WHY PYRAMIDS AND DIETARY GUIDELINES DON'T WORK

Dietary guidelines, pyramids and charts have all failed to make Americans healthier. Why are they not working? Institutions are made up of individuals who are a cross-section of society who are therefore personally dealing with the same lifestyle issues about eating and exercise, as are all consumers.

Dietary guidelines do not work, because the vast majority of the food and beverage industry does not incorporate them into food choices and portion sizes we see on the shelves. Remember, this is from the perspective of the institution and its responsibility and in no way diminishes the personal responsibility of every individual to take charge of their own lifestyle and choices. Our children need special guidance to learn what personal responsibility means. That guidance must come from adults.

GOVERNMENT SETS THE STANDARD AS A LEADER

Emission controls in the automobile industry have resulted in smaller, cleaner, and more fuel-efficient cars; though more work remains to be done. These successes were accomplished through government regulation through the Clean Air Act and similar initiatives. We have another just as pressing form of pollution going on in America: health pollution.

HEALTH POLLUTION

We have a health pollution crisis on our hands in America, and - as with automobile emission regulations - the food and beverage industry needs to be regulated to meet improved standards for healthy eating through strict labeling, reduced portion sizes, and regulation and disclosure of unhealthy ingredients in our country's food supply.

The free market society needs some governmental fine-tuning in order to save American lives and prevent suffering. The cost of not doing so is enormous. Heart disease, cancer, stroke, and diabetes (the four leading causes of death in the U.S.), and obesity, hypertension, and osteoporosis are all linked to diet and exercise. Americans and their children are the most over-fed and under-nourished group of people in the world.

One out of two Americans is overweight. One-third of Americans are obese. Being overweight is the second leading cause of preventable death in the U.S.

ILLNESS AND DISEASE IS COSTING AMERICA BIG BUCKS

The total cost of stroke to the United States is estimated at about $43 billion per year.
$28 billion per year direct costs for medical care and therapy.
$15,000 is the average cost of care for a patient for up to 90 days after a stroke.
$35,000 for 10% of patients, the cost of care for the first 90 days after a stroke.

*Statistics compiled from the Pennsylvania Health Care Cost Containment Council "Hospital Performance Report: 28 Common Medical Procedures and Treatments" (December 2002)

FOOD AND BEVERAGE INDUSTRY

The food and beverage industry as well as the health and wellness industry have a leadership responsibility to clean up their marketing. Misinformation and misleading claims are rampant. Observe carefully and you will detect the emotion-laden words, which are associated with poor choices and portion sizes:

Convenient (over-processed)
All natural (so is lard and corn syrup)
Lite or light (lots of added sugar)
Quick and easy (huge amounts of sodium)
Simple (check the label; not so simple, unpronounceable ingredients.)

In addition, the list goes on:

Fun, exciting, easy, time saver, feels great, low-carb, no sugar, no fat, healthy, look great.

Will the food and beverage industry have an economic price to pay for such changes? Yes, the transitional period will have some associated costs, in the short term. In the end, the food and beverage industry as well as consumers and our country as a whole will all benefit from a healthier America with healthier food choices. In fact, this will result in innovation and new areas of revenue for the food and beverage industry, all while actively contributing to making Americans and America healthier and stronger.

THE PUBLIC'S BASIC RIGHT TO KNOW

Disclosure is the law for government in Florida and many other states and federal entities. The Sunshine Law of Florida establishes a basic right of access to most meetings of boards, commissions and other governing bodies of state and local governmental agencies or authorities. It has led to not only a more informed public, but also actually better government.

Full disclosure on food labels would likewise inform the public and result in healthier foods being produced and marketed. True full disclosure for the average consumer must be in the form of a simple "level of healthiness" and "level of nutrients" grade. The factors determining the simple, easy-to-understand grade must be clearly defined in easily understandable language.

HEALTH POLLUTION A NATIONAL SECURITY ISSUE

The present health pollution of America is a national security issue because the consequences go much farther into sociological issues, such as increased crime and poor learning ability. An unhealthy America cannot perform or think as well.

LOOKING FORWARD

Whatever challenges our country faces will be better met if we are healthier in mind and body. Sick and unhealthy Americans are living longer and living with meds. These Americans need to be weaned back to health and off the meds, where possible. In most cases, lifestyle changes will result in improved health, independent of meals. Our physicians are challenged with a special institutional leadership role in strategizing to prescribe lifestyle-based changes and not just medication so that they and not just medication so that they truly can take on the role of healers, not only for the patient but also for the nation. Keep America strong. The medication mindset without healthy eating and exercise is killing Americans.

We have what it takes to change our culture for the betterment of all by taking personal responsibility for our lifestyles we lead. Our institutions have an equally important role model responsibility to set the tone and standard necessary to keep America healthy. Regardless of political affiliation, there should be complete agreement about personal and institutional responsibilities.

By Lt. Col. Bob Weinstein, USAR-Ret., author of Weight Loss - Twenty Pounds in Ten Weeks - Move It to Lose It

Lt. Col. Weinstein, nationally known as the Health Colonel, has been featured on the History Channel and specializes in a military-style workout for all fitness levels on Fort Lauderdale Beach in South Florida. He is the author of Boot Camp Fitness for All Shapes and Sizes, Weight Loss - Twenty Pounds in Ten Weeks - Move It to Lose It, Discover Your Inner Strength (co-author), Change Made Easy and Quotes to Live By.

His website: http://www.BeachBootCamp.net
Office 954-636-5351
Email TheHealthColonel@BeachBootCamp.net

A New Idea To The Health Insurance Crisis In America

Lack of health insurance coverage for over 41 million Americans is one of the nation's most pressing problems. While most elderly Americans have coverage through Medicare and nearly two-thirds of non-elderly Americans receive health coverage through employer-sponsored plans, many workers and their families remain uninsured because their employer does not offer coverage or they cannot afford the cost of coverage. Medicaid and the State Children's Health Insurance Program (SCHIP) or HAWK-I here in Iowa help fill in the gaps for low-income children and some of their parents, but the reach of these programs is limited. As a result, millions of Americans without health insurance face adverse health consequences because of delayed or foregone health care and extending coverage to the uninsured has become a national priority. -(Information taken from kff.org)

The number of people that are forced to go without health insurance is nothing less than a crisis in this country today. We have fallen into a vicious cycle over the last few decades in which health insurance premiums have become too expensive for even a middle class family to afford. This in turn results in the inability of the uninsured to cover medical costs which often times results in the financial ruins of the family, and in turn results in the continuing loss of income by the medical community, which in turn drives the cost of medical expenses higher, finally cycling back to the insurance company which then must drive the premiums of health insurance higher to help cover the rising cost of health care.

Many proposals have been tossed around by politicians on both sides of the isle ranging from socializing health care comparable to the Canadian system, to endorsing health savings accounts and cracking down on frivolous law suits against the medical community. Many of these proposals have good points, but along with whatever good points they bring they also bring major downfalls. For instance; a socialized national health care program would eliminate the need for health insurance all together and the cost would be taken on by taxes, which in theory doesn't seem like a bad idea. However, the downfalls to this system include a deficit in new doctors willing to get into the field due to the inevitable decline in income while the demand would grow due to no personal responsibility. In short if people didn't have to worry about deductibles or copays that would normally keep the person from seeking medical treatment for minor things, they would simply go to the doctor every time they had an ache or pain. So now we have waiting lines for people with major health problems since everyone is scheduling an appointment while at the same time we are loosing doctors due to lack of incentive.

The current battle cry by the republican Bush administration is to push HSA's (Health Savings Accounts) which reduce premium by taking a less expensive high deductible health insurance plan with a tax deferred savings account that earns a small interest on the side that you contribute to along with your premiums each month. Any money withdrawn from the savings account for qualified medical expenses are taken "tax-free", and unlike a flex spending account like many people are familiar with in employer based plans, you don't lose the money you put into the account that you don't use. Basically if you never used any of that money in the savings account you could withdrawal or roll it over into another vehicle once you turn 62 1/2 penalty free to be used for retirement. This is a viable option for some people, however for many the premiums for these plans are still too expensive, and the problem remains that if you need major treatment in the first few years of the policy you will not have a big enough amount in the savings account to help cover the gaps leaving that person responsible for a large portion of the cost out of pocket.

Now we come to what I believe is one of the biggest problems from a health insurance agent's point of view, which is the inability for persons with pre-existing health conditions to obtain coverage. From the number of people that contact my office searching for health insurance coverage, I would have to say that about half of them have a health condition that will either result in an insurance company declining that persons application, or result in an amendment rider which basically excludes coverage for any claims related to that condition. An example of a condition that I run across constantly is hypertension or high blood pressure. This condition will sometimes result in a company declining an application all together if other factors are involved, but most generally result in an amendment exclusion rider. You may think that this isn't that big of a deal, after all, blood pressure medicine is about the only thing they would have to pay for out of pocket, but what many people don't realize is that this rider will exclude ANYTHING that could be considered part of this condition including heart attacks, strokes, and aneurisms which would all result in a huge out of pocket claim. Consider the fact that my father had a double by-pass surgery recently that ended up with a final bill of around $150,000. This whole amount would have had to come out of pocket had he had a hypertension rider on his health insurance policy, not to mention the added cost of 2 months off of work thrown into the mix. On a modest income of $40,000 per year this would have ruined him financially.

So what how do we fix this problem? Obviously the proposals thus far have been flawed from the beginning, and even if one of these plans gained support from the American people chances are it would never be passed into law simply due to political infighting. One side wants to keep health care privatized while the other wants to socialize it, which as we discussed before both have upsides and downsides. It seems that we are doomed on this issue and there is no real ideas or light at the of the tunnel right? Maybe not, let me tell you about a client I had in my office a couple of years ago.

A young woman came in wanting to compare health insurance plans to see if there were any options for her and her family. She had several children and had been on Title 19 Medicaid and had been going to college paid by the state. She had recently graduated from college and had gotten a job with the local school system, however for whatever reason she was not eligible for health insurance benefits. Obviously she still couldn't afford 5 or 6 hundred dollars per month for a plan so she went back to the aid office and explained her situation. They ended up working with us to find an acceptable private health insurance plan and reimbursed her for a percentage of the cost which I didn't even know was possible!

This got me thinking, consider how many more people would be able to obtain coverage if they could be reimbursed by the government a percentage of the premium according to their income. For example; take a young married couple in their 20's with one child, let's say that their family income is $25,000 and that the average premium for a $500 deductible health insurance plan for them is $450. Just as an example let's say that the government determined that a three person family with an annual income of $25,000 is reimbursed 50% of their premium taking the actual cost to the family to $225 per month. This is now an affordable enough premium for the family to consider.

With this merging of private insurance with government assistance we get the best of both worlds. Of course the next question goes to cost, how much more would this cost the American tax payer and how much would this raise taxes? I don't think that it would cost the tax payers much more an here's why I think that: First off we would bring down significantly the amount of uninsured people that are unable to pay for the medical care they get in turn driving down the total cost of health care. Secondly the number of people that are forced into bankruptcy and driven to Medicaid Title 19 assistance due to medical bills stemming from catastrophic medical conditions that don't have health insurance coverage would be significantly reduced. This is important to keep in mind considering that once someone is on Medicaid they are receiving health care basically 100% covered by the government so there is no more incentive to not seek treatment for minor or non-existing conditions. On the flip side many conditions that would have not been caught before they became severe because a person didn't seek treatment due to not having insurance coverage would now be caught before they turned into a catastrophic claim. Finally, if the government allocated a certain amount of money to help cover claims by people that have pre-existing conditions the private insurance companies could do away with exclusions and declines due to already existing health problems, this is already done is some states such as the HIPIOWA Iowa Comprehensive Plans which insures Iowa residents that can not obtain coverage elsewhere.

You may be sitting there thinking that this is all just wishful thinking and that these ideas could never be implemented, but all of these ideas are already being implemented. The problem is that only some states do some programs and not even most health insurance agents know that some low income families can get reimbursed for health insurance premiums. If these programs were all standardized and put into effect on a national well publicized level I believe it would put one hell of a dent in the uninsured population in this country. Now I don't pretend to know what the reimbursement levels should be for what income levels but I do know that anything is better than nothing, and in my opinion this is the best middle ground we could find. The Democrats would be happy with the socialized aspect of the reimbursement, and the republicans should be happy that health care remains privatized giving this solution a better chance at a by-partisan backing.

I have faxed this idea to several senators and congressmen but always received the same type of standard response about how they are concerned with health care and that they are working hard to find a solution knowing full well that no one really even read my letters. The only way to get these ideas out into the public is for you that read this to pass it on to others by word of mouth, by email, or by linking your websites to this webpage. If enough buzz is created than these ideas would get the consideration that they deserve, and if enough people like you and I demanded that a solution be found than perhaps enough stress can be placed on the politicians to get something done. The number of uninsured Americans is only going to go up, the cost of health care is only going to go up, and the cost of health insurance premiums are only going to go up if something isn't done now! Until then the only thing that I as a health insurance agent can do is to compare all of the options out there and present you with the lesser of all of the evils, which in too many cases the option that is chosen is the biggest evil of going without coverage.

Written by Spencer L Fraise - Agent/Manger MultiQuote Insurance

[http://www.iowahealthinsurance.biz]

A Prescription For the Health Care Crisis

With all the shouting going on about America's health care crisis, many are probably finding it difficult to concentrate, much less understand the cause of the problems confronting us. I find myself dismayed at the tone of the discussion (though I understand it---people are scared) as well as bemused that anyone would presume themselves sufficiently qualified to know how to best improve our health care system simply because they've encountered it, when people who've spent entire careers studying it (and I don't mean politicians) aren't sure what to do themselves.

Albert Einstein is reputed to have said that if he had an hour to save the world he'd spend 55 minutes defining the problem and only 5 minutes solving it. Our health care system is far more complex than most who are offering solutions admit or recognize, and unless we focus most of our efforts on defining its problems and thoroughly understanding their causes, any changes we make are just likely to make them worse as they are better.

Though I've worked in the American health care system as a physician since 1992 and have seven year's worth of experience as an administrative director of primary care, I don't consider myself qualified to thoroughly evaluate the viability of most of the suggestions I've heard for improving our health care system. I do think, however, I can at least contribute to the discussion by describing some of its troubles, taking reasonable guesses at their causes, and outlining some general principles that should be applied in attempting to solve them.

THE PROBLEM OF COST

No one disputes that health care spending in the U.S. has been rising dramatically. According to the Centers for Medicare and Medicaid Services (CMS), health care spending is projected to reach $8,160 per person per year by the end of 2009 compared to the $356 per person per year it was in 1970. This increase occurred roughly 2.4% faster than the increase in GDP over the same period. Though GDP varies from year-to-year and is therefore an imperfect way to assess a rise in health care costs in comparison to other expenditures from one year to the next, we can still conclude from this data that over the last 40 years the percentage of our national income (personal, business, and governmental) we've spent on health care has been rising.

Despite what most assume, this may or may not be bad. It all depends on two things: the reasons why spending on health care has been increasing relative to our GDP and how much value we've been getting for each dollar we spend.

WHY HAS HEALTH CARE BECOME SO COSTLY?

This is a harder question to answer than many would believe. The rise in the cost of health care (on average 8.1% per year from 1970 to 2009, calculated from the data above) has exceeded the rise in inflation (4.4% on average over that same period), so we can't attribute the increased cost to inflation alone. Health care expenditures are known to be closely associated with a country's GDP (the wealthier the nation, the more it spends on health care), yet even in this the United States remains an outlier (figure 3).

Is it because of spending on health care for people over the age of 75 (five times what we spend on people between the ages of 25 and 34)? In a word, no. Studies show this demographic trend explains only a small percentage of health expenditure growth.

Is it because of monstrous profits the health insurance companies are raking in? Probably not. It's admittedly difficult to know for certain as not all insurance companies are publicly traded and therefore have balance sheets available for public review. But Aetna, one of the largest publicly traded health insurance companies in North America, reported a 2009 second quarter profit of $346.7 million, which, if projected out, predicts a yearly profit of around $1.3 billion from the approximately 19 million people they insure. If we assume their profit margin is average for their industry (even if untrue, it's unlikely to be orders of magnitude different from the average), the total profit for all private health insurance companies in America, which insured 202 million people (2nd bullet point) in 2007, would come to approximately $13 billion per year. Total health care expenditures in 2007 were $2.2 trillion (see Table 1, page 3), which yields a private health care industry profit approximately 0.6% of total health care costs (though this analysis mixes data from different years, it can perhaps be permitted as the numbers aren't likely different by any order of magnitude).

Is it because of health care fraud? Estimates of losses due to fraud range as high as 10% of all health care expenditures, but it's hard to find hard data to back this up. Though some percentage of fraud almost certainly goes undetected, perhaps the best way to estimate how much money is lost due to fraud is by looking at how much the government actually recovers. In 2006, this was $2.2 billion, only 0.1% of $2.1 trillion (see Table 1, page 3) in total health care expenditures for that year.

Is it due to pharmaceutical costs? In 2006, total expenditures on prescription drugs was approximately $216 billion (see Table 2, page 4). Though this amounted to 10% of the $2.1 trillion (see Table 1, page 3) in total health care expenditures for that year and must therefore be considered significant, it still remains only a small percentage of total health care costs.

Is it from administrative costs? In 1999, total administrative costs were estimated to be $294 billion, a full 25% of the $1.2 trillion (Table 1) in total health care expenditures that year. This was a significant percentage in 1999 and it's hard to imagine it's shrunk to any significant degree since then.

In the end, though, what probably has contributed the greatest amount to the increase in health care spending in the U.S. are two things:

1. Technological innovation.

2. Overutilization of health care resources by both patients and health care providers themselves.

Technological innovation. Data that proves increasing health care costs are due mostly to technological innovation is surprisingly difficult to obtain, but estimates of the contribution to the rise in health care costs due to technological innovation range anywhere from 40% to 65% (Table 2, page 8). Though we mostly only have empirical data for this, several examples illustrate the principle. Heart attacks used to be treated with aspirin and prayer. Now they're treated with drugs to control shock, pulmonary edema, and arrhythmias as well as thrombolytic therapy, cardiac catheterization with angioplasty or stenting, and coronary artery bypass grafting. You don't have to be an economist to figure out which scenario ends up being more expensive. We may learn to perform these same procedures more cheaply over time (the same way we've figured out how to make computers cheaper) but as the cost per procedure decreases, the total amount spent on each procedure goes up because the number of procedures performed goes up. Laparoscopic cholecystectomy is 25% less than the price of an open cholecystectomy, but the rates of both have increased by 60%. As technological advances become more widely available they become more widely used, and one thing we're great at doing in the United States is making technology available.

Overutilization of health care resources by both patients and health care providers themselves. We can easily define overutilization as the unnecessary consumption of health care resources. What's not so easy is recognizing it. Every year from October through February the majority of patients who come into the Urgent Care Clinic at my hospital are, in my view, doing so unnecessarily. What are they coming in for? Colds. I can offer support, reassurance that nothing is seriously wrong, and advice about over-the-counter remedies---but none of these things will make them better faster (though I often am able to reduce their level of concern). Further, patients have a hard time believing the key to arriving at a correct diagnosis lies in history gathering and careful physical examination rather than technologically-based testing (not that the latter isn't important---just less so than most patients believe). Just how much patient-driven overutilization costs the health care system is hard to pin down as we have mostly only anecdotal evidence as above.

Further, doctors often disagree among themselves about what constitutes unnecessary health care consumption. In his excellent article, "The Cost Conundrum," Atul Gawande argues that regional variation in overutilization of health care resources by doctors best accounts for the regional variation in Medicare spending per person. He goes on to argue that if doctors could be motivated to rein in their overutilization in high-cost areas of the country, it would save Medicare enough money to keep it solvent for 50 years.

A reasonable approach. To get that to happen, however, we need to understand why doctors are overutilizing health care resources in the first place:

1. Judgment varies in cases where the medical literature is vague or unhelpful. When faced with diagnostic dilemmas or diseases for which standard treatments haven't been established, a variation in practice invariably occurs. If a primary care doctor suspects her patient has an ulcer, does she treat herself empirically or refer to a gastroenterologist for an endoscopy? If certain "red flag" symptoms are present, most doctors would refer. If not, some would and some wouldn't depending on their training and the intangible exercise of judgment.

2. Inexperience or poor judgment. More experienced physicians tend to rely on histories and physicals more than less experienced physicians and consequently order fewer and less expensive tests. Studies suggest primary care physicians spend less money on tests and procedures than their sub-specialty colleagues but obtain similar and sometimes even better outcomes.

3. Fear of being sued. This is especially common in Emergency Room settings, but extends to almost every area of medicine.

4. Patients tend to demand more testing rather than less. As noted above. And physicians often have difficulty refusing patient requests for many reasons (eg, wanting to please them, fear of missing a diagnosis and being sued, etc).

5. In many settings, overutilization makes doctors more money. There exists no reliable incentive for doctors to limit their spending unless their pay is capitated or they're receiving a straight salary.

Gawande's article implies there exists some level of utilization of health care resources that's optimal: use too little and you get mistakes and missed diagnoses; use too much and excess money gets spent without improving outcomes, paradoxically sometimes resulting in outcomes that are actually worse (likely as a result of complications from all the extra testing and treatments).

How then can we get doctors to employ uniformly good judgment to order the right number of tests and treatments for each patient---the "sweet spot"---in order to yield the best outcomes with the lowest risk of complications? Not easily. There is, fortunately or unfortunately, an art to good health care resource utilization. Some doctors are more gifted at it than others. Some are more diligent about keeping current. Some care more about their patients. An explosion of studies of medical tests and treatments has occurred in the last several decades to help guide doctors in choosing the most effective, safest, and even cheapest ways to practice medicine, but the diffusion of this evidence-based medicine is a tricky business. Just because beta blockers, for example, have been shown to improve survival after heart attacks doesn't mean every physician knows it or provides them. Data clearly show many don't. How information spreads from the medical literature into medical practice is a subject worthy of an entire post unto itself. Getting it to happen uniformly has proven extremely difficult.

In summary, then, most of the increase in spending on health care seems to have come from technological innovation coupled with its overuse by doctors working in systems that motivate them to practice more medicine rather than better medicine, as well as patients who demand the former thinking it yields the latter.

But even if we could snap our fingers and magically eliminate all overutilization today, health care in the U.S. would still remain among the most expensive in the world, requiring us to ask next---

WHAT VALUE ARE WE GETTING FOR THE DOLLARS WE SPEND?

According to an article in the New England Journal of Medicine titled The Burden of Health Care Costs for Working Families---Implications for Reform, growth in health care spending "can be defined as affordable as long as the rising percentage of income devoted to health care does not reduce standards of living. When absolute increases in income cannot keep up with absolute increases in health care spending, health care growth can be paid for only by sacrificing consumption of goods and services not related to health care." When would this ever be an acceptable state of affairs? Only when the incremental cost of health care buys equal or greater incremental value. If, for example, you were told that in the near future you'd be spending 60% of your income on health care but that as a result you'd enjoy, say, a 30% chance of living to the age of 250, perhaps you'd judge that 60% a small price to pay.

This, it seems to me, is what the debate on health care spending really needs to be about. Certainly we should work on ways to eliminate overutilization. But the real question isn't what absolute amount of money is too much to spend on health care. The real question is what are we getting for the money we spend and is it worth what we have to give up?

People alarmed by the notion that as health care costs increase policymakers may decide to ration health care don't realize that we're already rationing at least some of it. It just doesn't appear as if we are because we're rationing it on a first-come-first-serve basis---leaving it at least partially up to chance rather than to policy, which we're uncomfortable defining and enforcing. Thus we don't realize the reason our 90 year-old father in Illinois can't have the liver he needs is because a 14 year-old girl in Alaska got in line first (or maybe our father was in line first and gets it while the 14 year-old girl doesn't). Given that most of us remain uncomfortable with the notion of rationing health care based on criteria like age or utility to society, as technological innovation continues to drive up health care spending, we very well may at some point have to make critical judgments about which medical innovations are worth our entire society sacrificing access to other goods and services (unless we're so foolish as to repeat the critical mistake of believing we can keep borrowing money forever without ever having to pay it back).

So what value are we getting? It varies. The risk of dying from a heart attack has declined by 66% since 1950 as a result of technological innovation. Because cardiovascular disease ranks as the number one cause of death in the U.S. this would seem to rank high on the scale of value as it benefits a huge proportion of the population in an important way. As a result of advances in pharmacology, we can now treat depression, anxiety, and even psychosis far better than anyone could have imagined even as recently as the mid-1980's (when Prozac was first released). Clearly, then, some increases in health care costs have yielded enormous value we wouldn't want to give up.

But how do we decide whether we're getting good value from new innovations? Scientific studies must prove the innovation (whether a new test or treatment) actually provides clinically significant benefit (Aricept is a good example of a drug that works but doesn't provide great clinical benefit---demented patients score higher on tests of cognitive ability while on it but probably aren't significantly more functional or significantly better able to remember their children compared to when they're not). But comparative effectiveness studies are extremely costly, take a long time to complete, and can never be perfectly applied to every individual patient, all of which means some health care provider always has to apply good medical judgment to every patient problem.

Who's best positioned to judge the value to society of the benefit of an innovation---that is, to decide if an innovation's benefit justifies its cost? I would argue the group that ultimately pays for it: the American public. How the public's views could be reconciled and then effectively communicated to policy makers efficiently enough to affect actual policy, however, lies far beyond the scope of this post (and perhaps anyone's imagination).

THE PROBLEM OF ACCESS

A significant proportion of the population is uninsured or underinsured, limiting or eliminating their access to health care. As a result, this group finds the path of least (and cheapest) resistance---emergency rooms---which has significantly impaired the ability of our nation's ER physicians to actually render timely emergency care. In addition, surveys suggest a looming primary care physician shortage relative to the demand for their services. In my view, this imbalance between supply and demand explains most of the poor customer service patients face in our system every day: long wait times for doctors' appointments, long wait times in doctors' offices once their appointment day arrives, then short times spent with doctors inside exam rooms, followed by difficulty reaching their doctors in between office visits, and finally delays in getting test results. This imbalance would likely only partially be alleviated by less health care overutilization by patients.

GUIDELINES FOR SOLUTIONS

As Freaknomics authors Steven Levitt and Stephen Dubner state, "If morality represents how people would like the world to work, then economics represents how it actually does work." Capitalism is based on the principle of enlightened self-interest, a system that creates incentives to yield behavior that benefits both suppliers and consumers and thus society as a whole. But when incentives get out of whack, people begin to behave in ways that continue to benefit them often at the expense of others or even at their own expense down the road. Whatever changes we make to our health care system (and there's always more than one way to skin a cat), we must be sure to align incentives so that the behavior that results in each part of the system contributes to its sustainability rather than its ruin.

Here then is a summary of what I consider the best recommendations I've come across to address the problems I've outlined above:

1. Change the way insurance companies think about doing business. Insurance companies have the same goal as all other businesses: maximize profits. And if a health insurance company is publicly traded and in your 401k portfolio, you want them to maximize profits, too. Unfortunately, the best way for them to do this is to deny their services to the very customers who pay for them. It's harder for them to spread risk (the function of any insurance company) relative to say, a car insurance company, because far more people make health insurance claims than car insurance claims. It would seem, therefore, from a consumer perspective, the private health insurance model is fundamentally flawed. We need to create a disincentive for health insurance companies to deny claims (or, conversely, an extra incentive for them to pay them). Allowing and encouraging aross-state insurance competition would at least partially engage free market forces to drive down insurance premiums as well as open up new markets to local insurance companies, benefiting both insurance consumers and providers. With their customers now armed with the all-important power to go elsewhere, health insurance companies might come to view the quality with which they actually provide service to their customers (ie, the paying out of claims) as a way to retain and grow their business. For this to work, monopolies or near-monopolies must be disbanded or at the very least discouraged. Even if it does work, however, government will probably still have to tighten regulation of the health insurance industry to ensure some of the heinous abuses that are going on now stop (for example, insurance companies shouldn't be allowed to stratify consumers into sub-groups based on age and increase premiums based on an older group's higher average risk of illness because healthy older consumers then end up being penalized for their age rather than their behaviors). Karl Denninger suggests some intriguing ideas in a post on his blog about requiring insurance companies to offer identical rates to businesses and individuals as well as creating a mandatory "open enrollment" period in which participants could only opt in or out of a plan on a yearly basis. This would prevent individuals from only buying insurance when they got sick, eliminating the adverse selection problem that's driven insurance companies to deny payment for pre-existing conditions. I would add that, however reimbursement rates to health care providers are determined in the future (again, an entire post unto itself), all health insurance plans, whether private or public, must reimburse health care providers by an equal percentage to eliminate the existence of "good" and "bad" insurance that's currently responsible for motivating hospitals and doctors to limit or even deny service to the poor and which may be responsible for the same thing occurring to the elderly in the future (Medicare reimburses only slightly better than Medicaid). Finally, regarding the idea of a "public option" insurance plan open to all, I worry that if it's significantly cheaper than private options while providing near-equal benefits the entire country will rush to it en masse, driving private insurance companies out of business and forcing us all to subsidize one another's health care with higher taxes and fewer choices; yet at the same time if the cost to the consumer of a "public option" remains comparable to private options, the very people it's meant to help won't be able to afford it.

2. Motivate the population to engage in healthier lifestyles that have been proven to prevent disease. Prevention of disease probably saves money, though some have argued that living longer increases the likelihood of developing diseases that wouldn't have otherwise occurred, leading to the overall consumption of more health care dollars (though even if that's true, those extra years of life would be judged by most valuable enough to justify the extra cost. After all, the whole purpose of health care is to improve the quality and quantity of life, not save society money. Let's not put the cart before the horse). However, the idea of preventing a potentially bad outcome sometime in the future is only weakly motivating psychologically, explaining why so many people have so much trouble getting themselves to exercise, eat right, lose weight, stop smoking, etc. The idea of financially rewarding desirable behavior and/or financially punishing undesirable behavior is highly controversial. Though I worry this kind of strategy risks the enacting of policies that may impinge on basic freedoms if taken too far, I'm not against thinking creatively about how we could leverage stronger motivational forces to help people achieve health goals they themselves want to achieve. After all, most obese people want to lose weight. Most smokers want to quit. They might be more successful if they could find more powerful motivation.

3. Decrease overutilization of health care resources by doctors. I'm in agreement with Gawande that finding ways to get doctors to stop overutilizing health care resources is a worthy goal that will significantly rein in costs, that it will require a willingness to experiment, and that it will take time. Further, I agree that focusing only on who pays for our health care (whether the public or private sectors) will fail to address the issue adequately. But how exactly can we motivate doctors, whose pens are responsible for most of the money spent on health care in this country, to focus on what's truly best for their patients? The idea that external bodies---whether insurance companies or government panels---could be used to set standards of care doctors must follow in order to control costs strikes me as ludicrous. Such bodies have neither the training nor overriding concern for patients' welfare to be trusted to make those judgments. Why else do we have doctors if not to employ their expertise to apply nuanced approaches to complex situations? As long as they work in a system free of incentives that compete with their duty to their patients, they remain in the best position to make decisions about what tests and treatments are worth a given patient's consideration, as long as they're careful to avoid overconfident paternalism (refusing to obtain a head CT for a headache might be overconfidently paternalistic; refusing to offer chemotherapy for a cold isn't). So perhaps we should eliminate any financial incentive doctors have to care about anything but their patients' welfare, meaning doctors' salaries should be disconnected from the number of surgeries they perform and the number of tests they order, and should instead be set by market forces. This model already exists in academic health care centers and hasn't seemed to promote shoddy care when doctors feel they're being paid fairly. Doctors need to earn a good living to compensate for the years of training and massive amounts of debt they amass, but no financial incentive for practicing more medicine should be allowed to attach itself to that good living.

4. Decrease overutilization of health care resources by patients. This, it seems to me, requires at least three interventions:

* Making available the right resources for the right problems (so that patients aren't going to the ER for colds, for example, but rather to their primary care physicians). This would require hitting the "sweet spot" with respect to the number of primary care physicians, best at front-line gatekeeping, not of health care spending as in the old HMO model, but of triage and treatment. It would also require a recalculating of reimbursement levels for primary care services relative to specialty services to encourage more medical students to go into primary care (the reverse of the alarming trend we've been seeing for the last decade).

* A massive effort to increase the health literacy of the general public to improve its ability to triage its own complaints (so patients don't actually go anywhere for colds or demand MRIs of their backs when their trusted physicians tells them it's just a strain). This might be best accomplished through a series of educational programs (though given that no one in the private sector has an incentive to fund such programs, it might actually be one of the few things the government should---we'd just need to study and compare different educational programs and methods to see which, if any, reduce unnecessary patient utilization without worsening outcomes and result in more health care savings than they cost).

* Redesigning insurance plans to make patients in some way more financially liable for their health care choices. We can't have people going bankrupt due to illness, nor do we want people to underutilize health care resources (avoiding the ER when they have chest pain, for example), but neither can we continue to support a system in which patients are actually motivated to overutilize resources, as the current "pre-pay for everything" model does.

CONCLUSION

Given the enormous complexity of the health care system, no single post could possibly address every problem that needs to be fixed. Significant issues not raised in this article include the challenges associated with rising drug costs, direct-to-consumer marketing of drugs, end-of-life care, sky-rocketing malpractice insurance costs, the lack of cost transparency that enables hospitals to paradoxically charge the uninsured more than the insured for the same care, extending health care insurance coverage to those who still don't have it, improving administrative efficiency to reduce costs, the implementation of electronic medical records to reduce medical error, the financial burden of businesses being required to provide their employees with health insurance, and tort reform. All are profoundly interdependent, standing together like the proverbial house of cards. To attend to any one is to affect them all, which is why rushing through health care reform without careful contemplation risks unintended and potentially devastating consequences. Change does need to come, but if we don't allow ourselves time to think through the problems clearly and cleverly and to implement solutions in a measured fashion, we risk bringing down that house of cards rather than cementing it.

Please visit Dr. Lickerman's blog at http://happinessinthisworld.com to read other articles about achieving health and happiness. He can be reached at alickerman@gmail.com.