By Donald
B. Ardell – August 02, 2009
Every morning when I wake up, I experience an exquisite joy
- the joy of being Salvador Dalí - and I ask myself in rapture, 'What wonderful
things this Salvador Dalí is going to accomplish today?'
Salvador Felipe Jacinto Dalí, 1904 – 1989
INTRODUCTION - ONE CHANGE AT A TIME, PLEASE!
The U.S. health (medical) care system is extraordinarily
large, costly and complex, as was Dali. To expect President Obama, the
Congress and multiple industry sectors (including the doctors, drug makers,
hospitals or insurance companies) to support reforms that ameliorate all the
big problems is unrealistic. No
single plan can or will, in my view, address all or even most of the problems
effectively.
Each of the disaster areas of our medical system warrants
reform legislation targeted to specific dysfunctions. This reality applies
with particular force to matters of controlling costs, providing access for
all, raising quality of care, supporting groundbreaking research and
dramatically reducing waste and inefficiencies. Attempts to shape a
single reform package that does all these things are courting failure.
(Image: William Hogarth, 1697-1764, A Going! A Going! The Museum of the
Royal Pharmaceutical Society, Great Britain.)
I have a modest proposal for dealing with what should be one
of if not the paramount goal for reform: creating conditions that encourage
healthful lifestyles. The ultimate goal for any system with the word health in
the name should be encouraging and even rewarding (positive incentives for)
citizen efforts to safeguard and advance their own best interests. I
leave to others those reforms that might best bring about cost controls, access
improvements, quality advances and so on.
My idea therefore addresses one issue or challenge -
promoting healthy lifestyles via positive mechanisms that can lead to quality of
life advances. In particular, my idea for a REAL wellness dimension to
system change is designed to promote an increase in the extent to which the
American people understand and come to exercise reason, experience of
exuberance in life and safeguard and enjoy personal and societal liberties or
freedoms.
In a moment, I will sketch the key element in my reform plan
for the health care system. The details will follow, in time, maybe after
I have been summoned to the White House or testified before Congress about my
plan.
For now, I'll just provide enough detail to demonstrate
beyond any doubt that my plan is brilliant and should be a priority for reform
legislation. But first, to set the mood and establish no doubt in the reader's
mind about how important reforms are to the future of America, an overview of
the current status quo seems in order. You never know - maybe some people
have not been paying attention for the past forty years and do not fully
realize how critical things are.
THE CURRENT U.S. MEDICAL SYSTEM - FRAGMENTED, COSTLY AND OTHERWISE A MESS!
Everyone seems to agree that proper reform is key to U.S.
economic stability. The health care system cost $2.4 trillion in 2007 -- $7,900
per person. Surely, these figures are much higher two years down this
troubled road. Many Americans have no protection or access - that is, they do
not have any insurance (46 million estimated) or are underinsured (25
additional million). Employer provided health insurance, cheap when it
began during WW II, is being phased out because companies can no longer afford
it. This nation spends 52 percent more per person than does Norway, the
country with the next costliest system of medical care. In other words, we are
spending half again as much as ANY other country. You would think Americans
would be Earth models for elevated health status, given this kind of
spending. However, you could only think that if you've been living on the
moon or other remote location without any newspapers, media or books. Everyone connected
with civilization in some form knows better. We're not the healthiest folks -
not that medical spending could EVER lead to advanced health status. As
all wellness-oriented folks know, health beyond the margins of not being sick
is largely a consequence of lifestyle patterns, plus genetics, environment,
cultural supports and random chance. Quality medical care is vital for dealing
with injuries, illnesses and diseases - but never for enabling people to be
fit, sensible, happy, ethical, kind, loving and all the elements that go into
advanced well being. As I wrote about 100 years ago (40, actually),
Modern medicine is a wonderful thing but there are two problems - people expect
too much of it and too little of themselves. (High Level Wellness: An Alternative
To Doctors, Drugs And Disease, Rodale Press, 1976, p.3.)
Besides Norway, other nations with substantial investments
in their medical systems are the United Kingdom ($2,760 per person), France
($3,449) and Canada ($3,678). Of course, these figures are not so
impressive compared with our spending. (Data source: The Organization for
Economic Co-operation and Development.)
OK, our system is expensive, but critics of a government
option (favored by the president) argue that U.S. medical care is
superior. Maybe, but a lot of data suggest otherwise. We rank 50th in
life expectancy, and 43 countries have lower infant mortality rates (including
France and Sweden). (Data source: The CIA World Factbook.)
All sectors of the American political arena agree that some
reform is necessary. President Obama, Republican and Democratic members
of Congress, the American Medical Association and the insurance industry are
urging reforms - but they disagree with the Administration and with each other
about how to do it. President Obama and most of the Democrats want a
government-sponsored option similar to Medicare. They seek to forbid
insurers from discriminating against those with pre-existing conditions.
Much to my liking, the president's plan, at least at this stage, is likely to
contain incentives for wellness and preventive services.
The debate is about how to pay, how much to pay and who
should pay the most. Critics of the president's ideas for reform ask, How
does the president plan to pay for this?
The answer, of course, is he doesn't. That is,
President Obama has no intention to pay for it - and besides, he can't afford
it (despite his cool job laden with fantastic benefits - like Air Force One).
President Obama expects taxpayers to pay for it. Since we can assume he, too,
remains a taxpayer, I guess he DOES expect to pay for it, like the rest of us.
Obama suggests that part of the money will come from dollars saved by rooting
out waste, fraud and abuse in the system, particularly in Medicare and
Medicaid. In addition, Obama wants to reduce or eliminate many tax
deductions available to high-income Americans. Nearly all the non-rich Americans
like that last part.
That's where things are today. These are the problems
that most concern U.S. policy makers studying or advancing health or medical
system reform ideas.
So, you might be ready to ask, What exactly is Don's plan
for creating conditions that encourage healthful lifestyles?
MY PLAN: METROPOLITAN QUALITY OF LIFE COUNCILS (MQLCs)
No matter what reforms are passed to deal with the big
medical issues, public acceptance of the reforms established will be highly
desired. Support for the changes will be critical to their eventual
effectiveness. However, something special is needed to carry out that
part of reforms designed to promote healthy lifestyles. For that purpose, I
think the nation needs a return to citizen councils, spread across the nation,
established to offer advice and guidance for healthy lifestyles that advance
quality of life. I suggest they be called Metropolitan Quality Of Life Councils,
henceforth MQLCs
There is a solid precedent for this idea. In 1966,
Congress enacted a comprehensive nationwide health-planning program.
Public Law 89-749 was entitled the Partnership For Health Act. It
provided for state and regional health planning councils with consumer
majorities, a rather remarkable innovation at the time. Fifty statewide
councils and over two hundred area wide agencies were funded. These
organizations carried on, with varying effectiveness, for about half a decade
until superseded by new legislation in 1974. A few years later, most went
out of business.
The area wide or regional councils had little or no actual
power, and their record of effectiveness is mixed. Whatever the verdict,
some features of the 1966 legislation held a lot of promise. These
councils, if nothing else, provided a forum for citizens to participate in
public forums about a range of health system issues, particularly concerning
construction and expansion of medical care facilities.
Since my plan for promoting REAL wellness with new area wide
agencies (i.e., MQLCs) is somewhat inspired by this experience, I should note
my role in the early health planning movement. During the era spanning
the mid-sixties to the end of the 70's, I worked on area wide council-related
matters in four roles:
1. Evaluated and proposed structural forms for the
councils as a researcher for Dr. Paul Ellwood's Interstudy, a think-tank funded
by NIH, for about one year.
2. Served as executive director of two of the largest
public and non-profit area wide agencies - one in the Minneapolis/St. Paul
Area; the other in the San Francisco Bay Area - for six years.
3. Consultant/adviser to planning organizations
providing technical assistance as well as organizing and conducting workshops
and seminars (as a member of the Arthur Young and Company team funded by NIH
for this purpose) - for three years.
4. Editor of the American Journal of Health Planning -
for two years. In the last three roles, I campaigned for wellness as a
priority health planning function. In the near future, two essays that I
wrote and published in 1976 and 1978 will be made available online at my website. These ancient articles might
give anyone interested in the MQLC idea a sense of what consumer-led activists
can promote in seeking ways to make reason, exuberance and liberty contemporary
values as part of health system reform. The two articles are:
* From Omnibus Tinkering To High Level Wellness: The
Movement Toward Holistic Health Planning, American Journal of Health Planning,
October, 1976. Volume 1, Number 2, pp. 15-34.
* High Level Wellness And The Health Systems
Agencies': A Health Planning Success Story, Volume 3, Number 3, July 1978, pp.
1-18.
A FEW SUGGESTIONS ON THE FUNDING, STRUCTURE AND ROLE OF MQLCs
I suggest that the health system reform bill contain modest
funding for a dozen or fewer demonstration or pilot MQLCs - and invite
states to compete for funds to establish these and other consumer led councils
(if the MQLC experiment proves successful). Instead of assigning the task
of setting out criteria for proposal assessment and program administration to a
medical agency - most likely the Department of Health and Human Services - the
Congress should ensure that the legislation as written assigns this role to a
Consumer Financial Protection Agency, such President Obama is seeking. He
wants to offer greater consumer protections and more transparent rules and
regulations. This placement would help avoid pressures and biases that could
allow health industry forces to dominate and medicalize the REAL wellness
agenda that MQLCs should be designed to promote.
The role of MQLCs would be to promote advances in health
status. Citizen education and support for local groups to conduct genuine
wellness education (including for schools and companies) would be a priority
for the councils. The focus would always be on the promotion of wellness
lifestyles that advance quality of life. Topics to address and promote
would include exercise and fitness, good nutrition and the REAL (reason,
exuberance and liberty) topics linked to quality of life, such as but not
limited to happiness, ethics, meaning and purpose, environmental responsibility
(global awareness) and critical thinking.
Among other tasks, the pilot MQLCs would prepare, with
public input, Quality of Life Plans for the area served while maintaining
websites and employing all manner of media to educate the public about REAL
wellness ideas and stimulating all to recognize the differences between good
medical care - largely a system responsibility, and quality of life - a mission
entirely in their hands.
Among other tasks, the pilot MQLCs would prepare, with
public input, Quality of Life Plans for the area served. They would
maintain websites and feed the media with newsworthy information and insights
about practical benefits of REAL wellness ideas. They would be charged with
stimulating citizens and public officials alike to recognize differences
between good medical care - a system responsibility - and quality of life, a
mission largely in the hands of each person.
The medical system problems, as noted at the beginning, are
large, costly and complex. The details for shaping councils such as I
propose, based roughly on the pioneering health planning, consumer-led agencies,
will require considerable study and ingenuity. I do not suggest that
anything about this idea is simple or easy. But, providing citizens with
a meaningful opportunity to translate and implement details of health reform,
oriented exclusively to health status advances rather than only medical reforms,
could and I believe would make a substantial and positive difference.
It's an idea for your consideration.
(Special thanks to several advisers who read and offered
advice on this essay, particularly Steve McDermott, Steve Jonas, David Randle, John
Sinibaldi and Bob Ludlow.)
Be well.
Don Ardell
is the Well Infidel. He favors
evidence over faith, reason over revelation and meaning and purpose over
spirituality. His enthusiasm for
reason, exuberance and liberty are reflected in his books (14), newsletter (490
editions of a weekly report) and lectures across North America and a dozen
other countries. He is very old
(over 40) but not slow (national and world triathlon champion). 