Health Care Reform: Where is the courage to expect accountability?

Douglas W. Jackson

The proposals for reforming the health care system in our country continue to evolve almost on a daily basis. We all watch, listen and read the coverage and analysis of the various proposals and compromises only to have the focus change the next day. Whatever form the final version of this modification takes, paying for the proposed increased coverage and holding escalating health care costs in check should be of critical importance to all of us as well as future generations.

My concerns, as I watch these changes unfold, are the lack of evidence and history that indicate any of the proposed plans will curtail rising health care costs. Rarely has government oversight ever, even with the use of price controls, been successful in controlling costs.

Personal accountability

I believe that individual accountability is a critical aspect for meaningful health care reform and cost savings, even though it has been carefully avoided in discussions and proposals by the Democratic leadership. As medical care becomes a right to which everyone is entitled, will anyone who is accepting “free health care” be responsible for controlling how much the government spends on that care? By receiving government-paid health care, the costs are no longer the individual’s concern.

The current system appears to be unsustainable and I feel President. Obama is not serving the public well if a new program does not require something from the recipients in return. Unless patients are involved in their own health care and have a financial stake (savings and/or increased costs) they will continue to maintain and perpetuate unhealthful lifestyles and behavior and the resultant overutilization of care. Ill-advised and ill-conceived reforms will potentially increase costs and see continued escalation in health care utilization.

In testimony before the Senate Committee on the Budget in February, Congressional Budget Office Director Douglas Elmendorf noted, “In many cases, the current system does not create incentives for doctors, hospitals, and other providers of health care — or their patients — to control costs. Significantly reducing the level or slowing the growth of health care spending below current projections will require substantial changes in those incentives.”

The government as an enabler

The current proposed government reforms provide a negative tax to many and increased taxation of businesses and the wealthy. An example of this negative taxing is in the form of federal subsidies to unhealthy foods and not taxing excessive sugar-added drinks and other snack foods. By not taxing these offenders, the government is an enabler that allows unhealthy individuals to be financially unaccountable for their choices.

The Centers for Disease Control (CDC) has stated a major portion of future health care spending will involve chronic diseases such as obesity, heart disease and diabetes. These diseases, in addition to smoking, excessive use of alcohol and prescription and illegal drugs, and violence will be covered as medical expenses by taxing those who make good health choices.

In the past, our political leaders stood up to the tobacco lobbyists and special interest groups and taxed cigarettes, perhaps it is time for them to take the same stance against unhealthy foods.

In an article in the April New England Journal of Medicine, Thomas Frieden, MD, and Kelly Brownell, PhD, the director of Yale’s Rudd Center for Food Policy and Obesity, proposed a penny-per-ounce excise tax on “sugared beverages.” They suggested they were the “single largest driver of the obesity epidemic.”

The CDC endorses a tax on soda and excessive sugar-added drinks. The soft-drink industry lobby says it is an overreaching use of the tax code to influence what people eat or drink.

This concept of causation was earlier emphasized in 2006 by the CDC at its obesity conference where they surmised that obese people spent 42% more for health care then normal-weight individuals. Furthermore, it estimates that obesity-related diseases have doubled over the past decade.

Political coverage

It will take some political courage to stand up and say that some of the biggest reductions in future health care costs could result simply from eating healthy, losing excessive weight, exercising regularly and smoking cessation — all of which require individual accountability. Two-thirds of the total increase in health care spending from 1987 to 2000 was due to an increased prevalence in chronic disease related to abuse in these areas — a $211 billion increase in health care costs.

I see examples of this every day in my office with some patients taking many prescription drugs for hypertension, fluid retention, diabetes, and elevated cholesterol levels. Their health care providers give them more pills, but neither they nor the patient address their obesity and lack of exercise.

Gain without pain

We cannot have it both ways. Holding down costs while trying to provide additional coverage without individual accountability will not work. It would require an enormous change in the current coverage policies, particularly in Medicare, which under existing rules covers all treatments with net medical benefits, regardless of cost and patient choices.

Elmendorf furthered this philosophy in this testimony. He said, “Given the central role of medical technology in cost growth, reducing or slowing spending over the long term would probably require decreasing the pace of adopting new treatments and procedures or limiting the breadth of their application.”

In other words, we cannot continue to buy people’s health and longevity. Bad choices in areas such as calorie consumption, healthy food, lifestyles and exercise should not be subsidized by society. Everyone needs to make sacrifices for health care reform to work, not just the “wealthy.”

Where is the courage and real leadership in our legislators in health care reform? The idea that health care reform should be all gain for some and all pain for others is not only unfair, it is unobtainable. Hopefully, individual accountability will emerge as an issue as compromises are made and special interest groups accommodated. The tax payer and patient could be the potential benefactor of meaningful reform, but there needs to be some real changes in the apparent direction to bring that to fruition.

Douglas W. Jackson. MD
Chief Medical Editor