As Seen on Forbes: Obamacare, Trumpcare... Who Cares?
By Jeff Margolis
After years of debate on health care reform, Obamacare is still in limbo. That doesn’t mean that the two parties can’t still come together to improve health care, though.
Rather than tearing down Obamacare or rehashing Trumpcare, we should be asking the real question: How do we, as a nation, derive significantly more value for every health care dollar spent?
Now is the time to change the dialogue around health care from wealthy versus the poor. The conversation should be about anybody – wealthy or less-wealthy, healthy or less-healthy – getting better value out of the dollars devoted to our health care system.
On any given day, the majority of people – wealthy or poor – are not patients receiving care, but rather consumers making choices that impact our health and move us towards or away from the need for medical interventions. There is high-consensus across the medical, insurance, employer and academic communities that only about 30% of a person’s health status is driven by the quality of medical care they receive in combination with their genetics. The most important factors in health are daily lifestyle and environment, driving as much as 70% of health status, according to many experts. And yet, our policy makers keep getting pulled to the gravitational black hole of arguing about medical benefit, while the people who can have the largest influence on health status and cost -- individual consumers -- are systematically lacking information, resources and incentives to make the best daily choices.
Common ground is solving the equation of improving health care value.
As published in my bi-partisan endorsed book, The Healthcare Cure (2011, Prometheus), health care value equals the health status of an individual or population divided by the costs of achieving that health status. In other words, if it takes expensive things to produce not-so-good health, that’s lower value. If we can do less expensive things that produce better health, that’s higher value. Various other health care industry leaders and academics have expressed similar definitions; the math is pretty simple, even if the input costs are not well-understood.
Let’s step back and look at the government as an operating system with a constrained budget. The U.S. government has been referred to as an “insurance company with a militia,” as that is how the numbers pencil out in terms of tax dollars at work. A recent update on U.S. tax spending shows that 48.2% of federal taxes are spent on Social Security, Medicare and Medicaid, and 19.8% on Defense and Veterans. That adds up to over two-thirds of federal spending; the effectiveness of this existing spending should clearly be a bi-partisan issue that precedes the question of additional spend.
We should all be able to agree that whether taxes go up or down, it’s just not intellectually honest to suggest that current spending on health care is optimized in terms of providing value. It is, as a matter of current systems design, wasteful and inefficient on many dimensions at the national, state, county and even community level. A primary reason for this is that the system as a whole is focused on the traditional “sickcare” side of the world, which treats illness and delivers medical care. But, medical services and medications are only part of the story for supporting healthy populations and individuals, yet legislators, policymakers and the media remain almost myopically fixated on it.
It makes economic sense to be more proactive in producing better health versus delivering reactive care for sickness.
There are two head-scratching quandaries that confront nearly anyone who looks at the U.S. health care system. The first is the widely-held belief that our doctors, hospitals and biotechnology are first-rate, and yet we always rank so unimpressively on the world stage of health care quality. The second is that our innovative capabilities in information technology is a source of pride among nations, and yet navigating the health care system for consumers is confusing, inefficient and inconvenient. Both dilemmas have the same root cause – a flawed systems design where we reactively try to fix downstream illness in people, which is both expensive and symptomatic of a greater issue.
If most of a person’s health status is not driven by medical care, then don’t we need to get consumers the personalized and targeted resources that will help them be as healthy as they can be given their situation? Shouldn’t we help consumers actively participate in being more responsible for their health and systematically incent them to do so, while acknowledging pre-existing conditions, age-differentials, financial constraints and spectrums of self-help capabilities? If we expect consumers to take on more responsibility for their health, we need to empower them to do so. Although ensuring a reasonable level of sick care benefits are available to all is certainly important, we should focus far more than we have on how we bring other types of general health improvement resources to the consumer as part of their health care benefits.
It makes economic sense to use information technology to better organize health improvement resources to produce and sustain better health.
There are manifold community, employer-based, city, county, and state health improvement and support resources to help people manage the daily determinants of health that are available – yet invisible – to most health care consumers. Social and behavioral support, nutrition, fitness, health literacy, chronic condition management, housing and employment assistance are what help our nation get upstream of expensive medical problems. But because these do not fall into the political sick care battleground, the things that drive 70% of a person’s health status are overlooked.
It’s appalling how little has been invested in health care information technology that impacts the majority of people, and how fragmented, difficult to understand and access the resources that could be delivering greater value for less to Medicaid recipients. The trouble is that most health technology investments have been concentrated on the sick care system, specifically electronic health records. While there is incremental value, we are not seeing the returns policy makers had anticipated or promised. This is due to the same systematic problem already mentioned.
There is a way to leverage technology and better organize and personalize health improvement resources for those who would greatly benefit from them – with no additional cost burden on the system and tax payers. Enterprise-level technology is now available to organize the cacophonous chaos consumers face, and connect them with the existing benefits most relevant to them. Systematically linking a pregnant Medicaid recipient with a prenatal app, a local healthy cooking class, and a digital diabetes prevention program provides social and economic returns that even the most skeptical of us can see value in. Proactively engaging Medicaid recipients, and any American for that matter, in their health has been proven to increase health care value, reduce costs and improve overall quality of life.
An opportunity for common ground that lowers total cost and improves health for our higher-needs population…and everybody else.
There is actually good news on the topic of empowering health care consumers within the morass of politics, but few people know it. The provision for health improvement programs and incentives for consumers in the current ACA legislation generally receives bi-partisan support. The legislation materially increased how health care premium dollars may be allocated to consumers for allowable health improvement program and incentives – up to 30% for general health improvement and up to 50% for the inclusion of smoking cessation programs. We need more of this: universal support of putting the power and resources into the hands of consumers to drive improved health and reduced costs across the board.
Honestly, it’s a big leap to embrace a systematic redesign of our nation’s health system that focuses upstream – on the production of better health – and puts information technology tools in the hands of consumers to be active participants in driving their overall health status. But as a 30-year health care industry veteran who has had the first-hand opportunity to apply systems design and information technology capabilities across nearly all types of health care entities, I can assure you that we – as a nation and an industry – can handle a bold move forward.
As health care dollars get squeezed, it’s time to put the spotlight on what provides exponential value: connecting consumers with personalized and localized health improvement resources to help them achieve and maintain their optimal health status.
We can most certainly find common ground across party and economic lines when it comes to health care. Everyone – regardless of wealth or politics – can agree that getting better value for every health care dollar spent is a worthwhile endeavor.
This article originally appeared on Forbes.com on Tuesday, December 12, 2017.