Public health and entitlement

Cathy wrote a thought-provoking comment on my last post, so I thought I would respond to it in its own entry.

I’d imagine costs for DM2 care had risen, like everything else, but was surprised to hear the thoughts about public health & nationalized health insurance. It’s been a long time since I took a public health class, but I’d been under the impression that they were cut from the same cloth. Now, that I think of it, I don’t hear about Medicaid paying for diabetes education, but then, I’m not familiar with who utilizes the program, and who pays for it, whether Medicaid, Medicare, or private insurers would reimburse the provider for diabetes classes.

Because pharmacists and ancillary staff deal primarily with drug therapy, we tend to think of the rising cost of healthcare as a result of the increase in the cost of prescription drugs. However this isn’t actually true. According to the CEO of Harvard Pilgrim, drug costs have been increasing at a rate of less than 5% per year, whereas medical expenses have been increasing at a rate of about 10%, so the increase in healthcare costs isn’t really driven by prescription drugs as much as is commonly thought.

In the long run, drugs tend to be cost-savers rather than cost-centers when utilized correctly, but that’s not news to anyone.

When you speak of $1 for public health are you saying ‘education & prevention’. If so, I would agree conceptually. There are probably long-term studies that prove this beyond a doubt.

Yes, that is what I mean, but I was unintentionally vague in my first post. I consider public health to be education and prevention in the form of programs and legislation design to try to have a long-term impact. I also consider public health to be (mostly) a public good in the economic sense of the term.

But the government considers public health to be quite a bit more than that, ranging from the IHS to Medicare/Medicaid to the FDA. When you look at their FY2009 budget (121 page PDF), I would have to cherry-pick the bits and pieces that I consider public health, add up their budgets and calculate the percentage of the whole… So clearly that’s not what Uncle Sam considers public health, and I should probably find a better term. “Education and prevention” like you suggested is good, but I think that’s a bit limited, because I see the laws that are being passed that prevent the sale of certain types of food in public schools to be public health, as well. Then there’s the work that the CDC does — particularly in containing and eradicating communicable diseases like smallpox and polio — and other things like providing clean drinking water and sanitation.

At the very least, though, I consider “public health” to be very separate from more traditional healthcare delivery.

And, so I’d venture your point is that any successful nationalized healthcare insurance-type or other type of program would need to incorporate a preventive arm with incentives for greater self-care. A lot of the obesity problem has to do with not bucking the current socially acceptable behaviors, i.e. too much availability of nutritionally cheap food, devaluation of importance of physical effort and exercise, sedentary lifestyle, plus knowledge deficits about foods and hidden human costs. Look at what happened when NYC banned trans fats, for example. I think the fallout will be realized in our lifetime, with a slowly falling domino effect.

Yes, a comprehensive wellness-type program would have to be instituted. I would go so far as to attach financial penalties to those who are wildly unhealthy. Think of it as almost like a Pigovian tax, if you will. Even if you return this money to the consumer at the end of the year in the form of an income subsidy, it’s still a powerful motivator to change because there’s a real financial pain associated with a specific aspect of their lifestyle. Then of course there’s the perennial moral hazard problem that’s never going to go away. It is true that if you are responsible for a greater part of your healthcare costs, you will go out of your way to make healthier choices to minimize the chances of becoming ill. (Just ask those who have consumer-directed health plans with high deductibles who pay out of pocket for “normal” medical care.)

But of course you need to fund pathways that would enable people to learn and make healthier lifestyle choices. You can’t just take an overweight smoker who works in a coal mine and has less than a high school education and tell him to lose 100lbs or he’ll pay more for his healthcare without setting a reasonable timetable and funding the education and exercise program that will help him get there. That’s just rotten and doesn’t help anyone.

What is troubling and will present problems in a nationalized system of healthcare is that Americans don’t like to hear the word “No.” We live in an entitled society where the customer is always right, and it’s our God-given right to have cheap gas, drive SUVs, eat our fast food, and spend our the government’s money on futile, end-of-life care. In other countries that have nationalized healthcare, there are very limited formularies in place, and many treatments and interventions aren’t covered at all, or if they are, there may be a multi-month waiting period to have that procedure. That kind of rationing would be tough for America to swallow. We seem to have this bizarre notion that simply because we are living, breathing human beings, we are entitled to X, Y, and Z, and we should have it now.

Obviously we’re not beautiful and unique snowflakes, and I think that the younger generations are beginning to recognize this as their thoughts linger on new ideas like “sustainability”, but I get the sense that the baby boomers are going to resist these kinds of necessary limitations.

Anyway, hope I answered your question.

3 thoughts on “Public health and entitlement

  1. Interesting chat about lifestyle choices. It’s great to see bloggers covering health care as we approach next week’s election. It is, without a doubt, an important and complex issue. Here at Public Agenda we’ve put together an informative non-partisan guide that focuses on the facts and on the plethora of perspectives surrounding the health care debate in America. Be sure to check it out at http://publicagenda.org/citizen/electionguides/healthcare and feel free to contact us with any questions.

  2. Thanks! I needed that.

    I’d seen the political ads on TV from the AMA, as well as had printed off AHA’s 2008 statement of principles for healthcare reform for a little night-time reading…

    The AP synopsis of diabetes drug costs in the newspaper this morning stated, “Diabetes drug costs soaring in the U.S.” Chicago- Americans with diabetes nealry doubled their spending on drugs for the disease in just six years, with the bill last year climbing to an eye-popping $12.5 billion. Newer, more costly drugs are driving the increase, said researchers, despite a lack of strong evidence for the new drugs’ greater benefits and safety. And there are more people being treated for diabetes. The new study follows updated treatment advice for DM2, issued last week.”

    Apparently, then, I’ve not read the first AP article.

    When I fill in at retail drugstores, I see a lot of generic metformin and glyburide dispensed (not so many ‘glitazones’ even from last year).

    From my hospital practice, I see insulin pens go out the door, and that the diabetes educator is pretty busy with getting info to the patient, so my impression is that we in healthcare doing a better job at detecting hyperglycemia and diagnosing DM2 comparatively to 10 years ago.

    So, as for drug costs, occasionally a Byetta drug rep will have detailed a doc and a patient will be admitted once in a blue moon on that expensive injectable, as well as the oral forms, but I don’t see so much fine-tuning with this type of drug–more emphasis on evaluation, diagnosis, and testing.

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