The Obamacare antidote: Your Personal Affordable Care Act by Vik Khanna; Book excerpt 4

The Affordable Care Act is a lie

Author’s Note:

Your Personal Affordable Care Act

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I am deeply grateful to Rachel Alexander and Steve Laib of The Intellectual Conservative for their willingness to carry this series of excerpts from my new e-book, Your Personal Affordable Care Act: How To Avoid Obamacare. As conservatives, we need to speak bluntly about the fact that not only is nothing free, but freedom — from government and industry intrusion into our lives — comes at a price in responsibility and accountability. My e-book provides the roadmap for doing just that.

This is Excerpt 4. See here for Excerpt 1, Excerpt 2, and Excerpt 3.

From Chapter 6…The Six Big Lies About U.S. Healthcare

Our healthcare industry is, without doubt, the most complex and contentious on earth. It is driven, unfortunately, not primarily by understanding the population’s needs and interests, but by the flow of money and power, which express themselves through law and regulations that are written primarily to benefit the healthcare provider and health plan industries. Six tall tales we’ll discuss shortly are worth dealing with head-on because they’re the reason we got Obamacare and why you need Your Personal Affordable Care Act.

According to the Organisation for Economic Cooperation and Development (OECD), no one outspends us when it comes to medical care, but many outlive us (http://www.oecd.org/els/health-systems/Health-at-a-Glance-2013.pdf).

Even more damning is the fact that every country on the list of nations that both spend less and live longer is also less overweight or obese than we are. We are the fattest culture in the history of Western civilization.

While many factors influence life span, this is a pretty severe indictment of a healthcare industry that clearly does not deliver value. I think most of us have to come to realistically expect that anytime we buy the most expensive product in a category, we anticipate getting something that is special and valuable. Not so in American healthcare, where we pay for a new Porsche every year and keep getting an AMC Pacer. And, instead of demanding better, we just get in, mumble our thanks, and drive the same piece of junk down the road hoping that, for us at that moment, it doesn’t disintegrate. Why are we so grateful for so little value?

The healthcare industry’s duplicitous design is not incidental. The more medical care providers ingrain the belief you get healthier only through them, the more money they make and the more power they accrue; this is called intervention bias and it is particularly harmful to people who aren’t ill and don’t need complex clinical services. It’s also harmful when a provider’s financial incentives conflict with the patient’s needs, such as when the cardiology center wants to place a stent in someone’s coronary artery, but doesn’t disclose that stenting would be no more effective than medical management and lifestyle change for many patients, nearly all of whom are operating with an incomplete data set.

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These kinds of small-minded automatons saturate our medical care industry. They’ve built an industry that aims to do more to you than you need because its primary claim to the mantle of success is volume and throughput, as though treating lots of people who don’t need care is trivial. This is also the chief lever for extracting more money from the rest of us, whether through taxes, health insurance premiums, or out of pocket payments. This is a dramatic and dubious departure from what have been the most important mantras of good health for time immemorial: you are your own best defense against the ravages of ill-health by making consistent, long-term use of the things your mother told you were true: eat wisely, play and exercise often, keep your stress level under control as best you can, and get plenty of sleep.

Interestingly, when I attended public health school at Johns Hopkins, people actually talked about a healthcare industry whose explicit goal was to create such a robust population it could largely put itself out of business. No one talks like that anymore. Now, we seem to talk only about ever larger healthcare institutions and increasing dependence on medical technology by a public that seems at once (understandably) confused about how to manage its own day-to-day healthy lifestyle needs, but also wary of disengaging from this unhealthy dance with a broken model of healthcare delivery for fear of missing out. Missing out on what, exactly?

The U.S. healthcare industry doesn’t just turn the concepts of population health upside down, it simply ignores them, and it worsens many of them by making into medical issues things that don’t inherently require a clinical intervention. This process is called “medicalization,” and its primary purpose is to create dependency on the professions and the institutions they run. Your dependence enhances their status and income. This is not to say there aren’t circumstances that require professional expertise; clearly, people get sick and have accidents and require complex and fast medical management. For these rare circumstances, it’s good to have a highly reactive and well-equipped system. But, people and organizations designed around the concept of fixing are not able to engage in the pursuit of prevention, because it is economically not in their interest to do so, and it is far afield from their core competencies. Medical management simply is not an essential ingredient for just living well.

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Lie 1: We needed health reform to solve the problem of people being uninsured for healthcare

According to both independent and government estimates, the uninsured cost the economy about $50 billion to $70 billion per year out of a total of $2.7 trillion in medical care spending (http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf). Thus, we overhauled one-sixth of our economy to fix a problem that comprised about 3 percent of total healthcare spending and had its greatest impact on hospitals, the majority of which are tax exempt and supposed to be providing free care as part of their tax-advantaged mission. This is like gutting and rebuilding your house because it needs new carpets.

Lie 2: We needed a national solution

Our fifty states vary widely in demography, geography, culture, traditions, politics, and industrial and economic bases. What’s palatable and desirable to people in Maryland may not suit the needs of South Dakotans. One of the most powerful elements of our style of republic is the ability of the states to experiment, even within a federal framework that encourages them to push toward a unified set of broadly stated goals.

Lie 3: Insuring the young and healthy will lower costs overall

Insuring the young and healthy will bring in revenue needed to pay for the care of older (pre-Medicare) adults who are sicker and need more care, but who won’t pay premiums that reflect their actual cost, utilization burden, habits, or health status. This makes the economics of the ACA much like the intergenerational Ponzi scheme known as Medicare, which has done more to drive overutilization and overspending than any other health policy scheme. Medicare’s codification of fee-for-service as the major reimbursement method did more than anything else to create a healthcare industry built around revenue cycles, not clinical excellence and safety. We rewarded doctors, hospitals, drug companies, and the like for doing more, whether or not more was necessary, instead of paying them for clinical safety and success. Breaking their addiction to the ATM is proving to be insanely difficult, and it may not be doable at all. It’s going to be even tougher as Obamacare goes forward, because they will be working together much more closely…all the better to ensure that everyone makes money and that issues of coverage and reimbursement align to meet industry needs.

Lie 4: The ACA helps average people more than it helps the healthcare industry

There is a reason the hospital and health plan industries fell into line and supported Obamacare so strongly. This is a full employment program for bureaucrats and technocrats because it helped create a stream of new customers for both industries. This is especially important for hospitals with unused capacity, which they will now try to fill by providing preventive care – such as screenings – that do nothing to reduce morbidity or mortality. No one has any idea whether the health of the population will actually improve. We do know, however, that both insurance coverage and the promotion of preventive care result in people having more done to them, frequently with no useful result and often with harms inflicted.

Lie 5: People need more preventive medical care, which will also help contain costs

It is crystal clear that people need less preventive care, which is mostly good only in theory, and not nearly as useful in reality. The first-dollar coverage for preventive care in the ACA will prove to be a massive driver of unnecessary healthcare spending. Truven Health Analytics, which employs wellness industry “thought leader,” Ron Goetzel, said as much in its report to clients (http://img.en25.com/Web/TruvenHealthAnalytics/EMP_12521_0513_CostDriverRB.pdf). Getting preventive care in the form of screenings is almost always a search for disease in people who don’t have it and who would benefit far more from long conversations with their doctors about how to take better care of themselves in order to stay out of the medical care industry for as long as possible.

Lie 6: Don’t worry, be happy; it’ll all work out

First and foremost, you should worry. There is zero evidence that staying fully and relentlessly engaged with the medical care industry will reduce costs or improve health. Indeed, Massachusetts, which gave us the state model for what became Obamacare, has the highest healthcare costs in the nation. Further, expanding Medicaid access in Oregon increased utilization of very costly emergency room care, which, we are told repeatedly, is not supposed to happen when people have insurance that promotes access to less expensive forms of primary care.

A young, fit, wealthy President who plays basketball and golf, jogs around the White House in his suit before lunching on first quality food, and lifts weights (sort of), should have drawn much different conclusions about how to improve the health of the American population…Ironically, this President’s healthcare reform pushes Americans into a kind of medical servitude. His goal should have been to lead people to greater health independence and to say that we want the smallest, most efficient healthcare industry we need to meet our requirements. (Why do political leaders always make that trite, hackneyed statement about the military and never about the healthcare industry?) Instead, he has empowered and promoted bloat, waste, and stupidity. Health reform, as we are seeing it now, is the product of a control-freak mentality…

In the final excerpt next week, I will provide some guidance on where I think we are headed from here.

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