“Healthcare” is supposed to be the big election issue, and politicians promise to give people universal and equal “healthcare,” or prevent the bad guys from taking it away.
Everyone of course wants to be healthy, and a $3 trillion industry wants to keep the money flowing.
So, I have a confession to make as a doctor: I don’t think I have ever kept anybody healthy. If someone comes to me asking for “health maintenance,” I don’t have a shot of “health” to give, or a prescription for “health” to be filled at your neighborhood Walgreens, CVS, or Rite-Aid.
And as a patient, I can’t recall any ways in which doctors kept me healthy, although they did save my life by taking out my appendix, and they treated some illnesses and injuries. I am very grateful to them, and whatever I paid them seemed reasonable and well worth it.
To my mind, a healthy person is one who does not have to see a “healthcare provider” regularly or take medicine every day, and who can go to work, take care of family, and generally lead an active life.
We hear endless complaints about how we spend too much money treating sickness instead of preventing it. If only we had the government take all the money, plus trillions more, and “invest” it in health, we wouldn’t have to spend so much, and everyone would be healthier—so they say.
This was the rationale for the National Health Service in Britain. Once the NHS took care of the backlog of untreated illnesses, much of the need for it would melt away. This did not happen. Expenditures kept rising and were never enough. The backlogs and waiting lists grew. Ambulances circle emergency departments, and patients are crammed into hallways and storage rooms.
Suppose you go for your government-funded, “value-based” health maintenance visit. Details of your once-private life will be entered into a very expensive electronic health record. (For most people, it will be their own data, but occasionally someone else’s will be cut-and-pasted in, causing endless trouble.) You will be checked for diabetes or pre-diabetes, hypertension or pre-hypertension, tobacco use, cholesterol, in many cases gun ownership, body mass index, and other government-mandated items. You will get educated about the evils of tobacco (in case you have been on Mars and hadn’t heard). You’ll be lectured about obesity if your BMI is too high. You’ll very likely get a prescription to lower your blood pressure or cholesterol, and you may get vaccinated for something.
Your provider will likely get a bonus for checking all the right boxes and for “keeping you healthy,” and will get penalized if your “numbers” don’t improve or you get sick. Since I don’t think others are any better than I am at creating health, there is a huge incentive to “manage the case mix” to discourage unhealthy or noncompliant patients from joining the practice.
People on drugs for blood pressure or cholesterol may feel worse rather than better, but are supposed to be less likely to have a heart attack or stroke decades later. Studies with huge numbers of patients, who may be very different from you, have shown a decrease in such events with treatment. So far, a decrease in expenditures has not been shown, in view of the cost of all the drugs and side effects.
Of course, as an internist I treat high blood pressure and diabetes, but I consider this to be disease management. Would better diet prevent these things? Possibly, but what diet? I recommended low-fat diets for years. This government-approved advice is now questioned.
So how would government-funded primary care have prevented the diseases my patients have had? Heart failure? (Statin drugs probably make it worse.) Heart attacks? (When the patient has one, it is too late to prevent it.) Stroke? (Preventive aspirin is now criticized because of the bleeding it may cause.) Osteoarthritis? (We have great joint replacements but are much better at blocking access to surgery than at curing the arthritis.) Gall bladder disease, cancer, pneumonia, blood clots, thyroid disease, cataracts, arrhythmias such as atrial fibrillation, herniated disks, asthma, endocarditis from drug abuse, on and on. If we put all the doctors to work pretending to keep people healthy, who would treat disease and injury?
Healing the sick is what medicine is about. The politicians who promise to “fix healthcare” can only destroy medicine—while bankrupting the country.