Water is more valuable than gasoline or gold. Millions of people in recent history have lived their entire lives without ever seeing an ounce of gold or using a gallon of gasoline but no one can live more than three days without water. All humans need a reliable source of water. It is a life-or-death issue. Healthcare is more like water than anything else that we use. For most of us, the time will come when we need good healthcare just as much as we need safe water. Your life depends on clean, pure wateand it depends on healthcare. Without good healthcare, I would have surely died of large cell lymphoma in 1990 when I was 43 years old. That is a rapidly growing cancer that is always fatal without treatment.
Most Americans get their drinking water from a water system that is owned by the community they live in. My town is like that. Greenville, SC has a population of 75,000 within the city limits and owns a great water system that serves 500,000 people. I have more faith in the quality of the water from my tap than I do in bottled water. Our water system is governed by the mayor, one city council member, and three elected commissioners. The water system owns the watersheds around two of the three upcountry lakes that supply our residents. “There are no residents, no commercial, agricultural or industrial facilities located within the watersheds.” It is some of the cleanest, safest water in the world. Those who live within the Greenville city limits pay $1.68 for 1000 gallons of water. One pint of bottled water at a gas station costs more. Water costs a great deal more in some communities. You may have heard about the community in Arizona that got cut off from the Scottsdale water supply. They are coming up with an answer, but “the price could be anywhere between $20 to $60 per 1,000 gallons of water.” That makes me really grateful for our public system here. Our water is a high value commodity. We have great water at low cost. Everyone understands that putting our water system in private hands would be very risky.
The same cannot be said for our healthcare system. Uniquely, among all of the developed countries in the world, we have a health system dominated by a few health insurance companies. These health insurance companies don’t answer to the public. They answer to their executives and stockholders. It is an experiment that has failed utterly, and it is time to do something different. Our system is the very definition of low value. We pay much more for healthcare than other developed countries and our results are much worse. Gross domestic product (GDP) is a term for the value of all goods and services produced in a country. We spend a higher percentage of GDP on healthcare than any other developed country. We spend 20%. The Europeans spend 10% and they live longer. Singapore spends 5% and they live longer. Despite the much higher cost of our healthcare, pregnant American women are ten times more likely to die during due to having a baby than a woman in New Zealand. How can we possibly defend that? We can’t. It is indefensible!
The people who are served by the health system own it in other developed countries. The system that is most like ours is in Germany. As in the US, most Germans get their health insurance through their employers. The employer pays the bill, but they don’t depend on large insurance companies that answer to stockholders to set the priorities of care. The insurance companies in Germany are run by elected employees and employer representatives. They live longer for half the impact on GDP. The story is the same in the United States. The best healthcare systems are owned by the people they serve. The Southcentral Foundation in Alaska serves Native Alaskans for half the money that it takes to serve other Alaskans and their quality scores are very high. The Vestra Health worksite clinic is owned by a tribal casino and it provides care for half the cost of members seen in the broader community. Both of these American efforts are driven by advanced primary care teams in the outpatient setting.
We have known for a long time that our system is utterly broken. Tweaking the current system will not work. We have not even begun to make the level of change that will be required to give us higher value healthcare. This is the kind of discussion that can lead to a system that serves us better. Talking about healthcare as a right does not work. Right away you will hear, “it is a matter of personal responsibility. I pay for my healthcare, why should I pay for yours.” Adding another should to the list does not work either. Tweaking the current system won’t change a thing. But understanding healthcare is as essential as water helps to frame the problem. Healthcare is like any other community services that we all own. If a community has good water, sewer, schools, and transportation, it is much more attractive to new residents and businesses. The community prospers.
The instant you begin to talk about changing our healthcare system, the people who run the show now start talking about socialized medicine to stoke the emotions and block the required changes. What is socialism really? “It is a political and economic theory of social organization which advocates that the means of production, distribution, and exchange should be owned or regulated by the community as a whole.” That’s it. Community water, sewer, schools, bus service, subways, and airports are most often socialist in their design and in most places they work well at low cost. They are essential to a strong community. They are governed by local people for the benefit of the community. Public ownership of healthcare that is governed by an elected commission makes all the sense in the world. Running around and screaming the sky is falling solves nothing.
I am not talking about a single payer system at all. I am talking about healthcare that is run by a local commission with priorities that are determined by elected officials who live where you live. You may think that you already have that in the large not-for-profit health system that dominates your area but nothing could be further from the truth. These systems are not run by an elected commission. They are governed by an appointed board. I have been on one of these boards. The CEO works with the board chair and a couple of other allies on the board. They determine the board agenda, and the rest of the board does not have much input. They usually rubber stamp the proposal. The CEO has tremendous influence, and his or her performance evaluation has nothing to do with health in the community. The board evaluates the CEO based on how profitable the system is and how well it is doing in competing with other health systems in the region. The greatest CEO rewards come from controlling healthcare in half a state with a strong profit margin. Again, community health is not part of the equation. The system produces what it is designed to produce.
These systems make more money when all the beds are full, and your population needs lots of expensive tests and specialty visits. There is no incentive to keep you healthy and free of chronic disease. There is every incentive to rescue you late after the damage has been done. That is our model. That is why it is so expensive and so ineffective. These big systems own all the primary care clinicians in your community, and they manage primary care to ensure referrals to the system for expensive tests, specialty visits, and admissions. So, what is the answer?
You can have world class medical excellence in your small to medium sized community. You can lead the way to a better health system—right now— today. Your community can support an independent advanced primary care practice that is focused on slowing the development and progression of the chronic diseases that cause most disability, death, and very high costs. We have experience with that kind of medicine. There is a small practice in rural Southwest Louisiana that is walking the walk. Patients seen in the clinic cost half as much as patients seen in the community. They are in the hospital one fifth as often and they are in the ER one third as often because this advanced primary care practice is keeping them healthier. My next post will discuss the practical steps to bring this kind of care to your community to make it more attractive to new residents and businesses. Set yourself apart! Let’s get started!
As you elaborate on this in subsequent posts, one question you might address is, “How would what you’re proposing differ from existing systems, such as Medicare, Medicaid and the VA medical system, all multi-billion-dollar, taxpayer-funded operations run by both elected and appointed officials, similar to the municipal services you cited?”
Another facet might consider & compare existing concierge, direct-pay medical clinics that have been around in recent decades and continue to multiply, grow and compete with existing systems.
Finally, what about end-user (or patient) responsibility? I rarely go to the doctor because I take good care of my health. When I do go, I often see morbidly obese people who obviously do not take care of their health, I understand the frustration that many doctors have expressed about revolving-door patients who never follow their advice for improving their health. Some, if not many, of these people are unable to pay, or choose to not pay, for their medical services. This gets passed on to those who do pay and drives up their costs.
Thank you for your exploration of this topic. Clearly an area that needs more thought and practical creativity for better outcomes.
I like the concept of the water system, except to say that, living in NYC, our thoughtful leaders are still poisoning our excellent NY water with fluoride. I am from Holland originally, where they briefly introduced fluoridation after the war, under American influence, but in the sixties they abandoned it again, after it became clear that the science was bunkum.
As to healthcare, I think the better model is that the first tier should be geared to prevention, and it should be organized as a mutual society, i.e. a member owned network, supported by tax credits for low income people, but it should be all about lifestyle medicine. We now have better testing available (Premier Heart's Multifunction Cardiogram (TM), talk to me!), which offers high-res diagnosis and prognosis for the entire cardiometabolic function, with a 10-minute non-invasive test, and with 90-100% accuracy. It should become the standard of care for early detection of all heart problems and also diabetes, for it can pick things up early, when lifestyle changes can still easily prevent or reverse the onset of problems. This is at the heart of almost all chronic diseases, which are driving up healthcare cost by being mistakenly medicalized when they should be addressed with lifestyle changes. That accounts for 80-90% of healthcare costs, if you can only eliminate half of that, you can solve the country's economic problems.
That first tier of healthcare should also include exercise and meditation schooling, and, importantly, 2nd opinions for anything that that happens in the second tier, which should be a proper insurance plan. The level of deductible in the 2nd tier should be based on the maintenance of adequate biomarkers as determined by the annual physical, so that unhealthy lifestyles are reflected in the insurance cost, but people are not excluded from healthcare.