We Should Have Higher Taxes!

 

Don't get me wrong here. I don't like paying taxes any more than anyone else does. Especially when I see how the government spends my money for me. But I am starting to warm to the idea of targeted consumption taxes intended to place the burden of societal costs on those who create those burdens.

Let's consider cigarette smoking as one example. In the United States, cigarettes are taxed at both the federal and state levels, in addition to any state and local sales taxes and local cigarette-specific taxes. There is no doubt that this is burdensome upon and unpopular among smokers. In New York State for example, a pack of cigarettes costs about $10 and roughly half of that cost is taxes. 

But here is the thing. Smoking imposes a very high cost on society, and I am expected to pay that cost through my own taxes, even though I don't smoke. Cigarette smoking cost the United States more than $600 billion in 2018 alone, including:

• More than $240 billion in healthcare spending
• Nearly $185 billion in lost productivity from smoking-related illnesses and health conditions
• Nearly $180 billion in lost productivity from smoking-related premature death
• $7 billion in lost productivity from premature death from secondhand smoke exposure.

As high as cigarette taxes may seem to smokers, in fact they raise less than $12 billion a year, leaving the other $588 billion for you and I to pay.

A consumption tax like that on cigarettes shifts at least some of the tax burden from society to those who create the costs through their consumption. No one is forced to pay this tax; no one is forced to smoke. Nor are they forbidden from doing so. They are just asked to contribute more to the costs their choice imposes on me.

This brings me around to my point (at last!). While tobacco use indeed imposes a steep cost on society, it pales in comparison to the costs imposed by over-consumption of sugar. A 2013 report estimated those costs as "in excess" of $1 trillion annually. Now, unlike cigarettes, I do consume sugar so taxing it would affect me directly. But I DO have control over how much of it I choose to consume. And in any case, if I think smokers should be financially responsible for the damage caused by their consumption of tobacco then I should also be help to account for the cost of my sugar habit.

Over 100 countries impose taxes on sugar already and have seen reductions in consumption as high as 30%. Such a reduction in the US would have huge and favorable impacts on rates of diabetes, obesity, heart disease and some cancers with concurrent reductions in healthcare spending. No one would be forced to stop consuming sugar and sugary products, only to pay more for the costs they are imposing on others.

When it comes to sugar, we should have higher taxes.

Why is Dental Care not Healthcare?

According to the US Centers for Disease Control and prevention, about one-quarter of Americans 65 and older have lost all of their teeth. One-third have untreated tooth decay, even though poor dental health is linked to heart problems and other health concerns seniors already face, such as diabetes. Almost 8,000 people in the United States die of oral and pharyngeal cancers every year, most of them elderly. But the problem is not limited to seniors. Children from lower-income families are twice as likely to have tooth decay

The bottom line is that although healthy teeth are essential for good overall health, they have never really been considered a part of the body by many insurers and third-party payers. Even though the links between oral health and numerous other conditions such as heart disease, pneumonia and fetal health are well known, more than 180 million Americans never visit a dentist.

The Affordable Care Act (ACA) brought health insurance coverage to millions of people who had never had it before. Not only did the sweeping changes put an end to exclusions for pre-existing conditions, but healthcare reform also designated 10 “essential benefits” that insurers must include in their plans, such as treatment for mental health problems and drug and alcohol abuse.

The idea was to provide coverage for things that could improve a person’s overall health at a relatively low cost. The theory? Keep people healthy by taking care of small problems before they become big, expensive ones.

The partition between dental and medical makes little sense given that “oral health is directly related to general health,” says Dr. Garry Glassman, an endodontist based in Toronto, Canada who also practices in the U.S. “The oral cavity is a gateway to your body. A lot of stuff in the mouth can indicate kidney disease, heart disease, diabetes, HPV, cancer, etc. Your dentist can be your first line of defense.”

Even if you do have dental insurance it is likely restricted to only certain procedures and carries an absurdly low annual payout cap - often $1,200. So why does something as basic as dental care continue to take a back seat, even with the new emphasis on preventive medicine?

The answer, apparently, is "because that is how it has always been".

Despite it being a plainly medical issue, until the 1800s, dentistry was the domain of barbershops, practiced in the same chair and usually by the same guy who shaved your beard. It’s so bizarre and frightful an image that it’s almost comical, but the history of our teeth and jaws being treated as something as incidental as our hair and nails still haunts us.

Meanwhile, millions of non-wealthy people continue to suffer the genuine agony and negative health consequences of bad teeth. Read more here.

Making Lifespan = Healthspan

When we think about living a long life, we picture ourselves in good health, mobile, active, spending time with family and friends and doing the things that we enjoy. In other words, we picture ourselves healthy, not simply alive. For most of us though, that is not how it is going to work out. We spend the first half of our lives sacrificing our health for money, and then spend the second half spending our money trying to restore our health. "We need to adjust our thinking and aim for 'healthspan'," says Prof. Michael Thorner, an endocrinologist at the University of Virginia. "Improving how long we have a robust and functional life."

In the United States in 2022, the average lifespan is 79 years (a bit higher for women and a bit lower for men, but not a lot). This is up from 66 years in 1960, quite an impressive improvement. But after age 60, 1 in 4 of us is diabetic and 60% of us have hypertension. At age 65, 41% of us will have cancer - 21% fatally. Our Lifespan is exceeding our Healthspan by 25 - 30 years! This is fantastic news if you are a healthcare provider or a pharmaceutical company. For the rest of us, no so much.

In the United States, we talk a lot about healthcare but what we are really talking about is sickcare. The entire system is focused on treating illness and disease after we have it. For Americans, medical expenses are the number one cause of personal bankruptcy. Yes, insurance is a big part of this problem. But a bigger part of it is that too many of us are just too sick in our senior years. Despite the fact that every one of us is going to get older and older until we die, there is little attention being paid to how we can age in a healthy way. 

There is a lot that you can do to make your lifespan equal your healthspan. Healthy Aging is completely possible. So what is it going to be? A long, infirm life? Or a long, healthy life? Lets explore that together.

Overtesting Your Heart

 

According to research by the American Heart Association and published in the journal Circulation earlier this year, about half of all US adults who undergo a heart procedure or test did not need it. 

The issue of "low-value" medical care is a longstanding one, the heart association notes. The term refers to health care services that are unlikely to benefit patients in a meaningful way, exposing them to potential harm and wasting money. It's estimated that low-value medical care accounts for about 30% of health care spending in the United States — or up to $101 billion annually.

Among the low-value tests and treatments are annual exercise stress tests for people who have undergone angioplasty or surgery to clear blocked arteries, echocardiograms to assess people who have fainted but show no signs or symptoms of heart problems, and coronary calcium tests for people already known to have heart disease.

Individual doctors may rely on their personal experience, and the belief that a test or treatment helps patients, and just stick with it. Or they may simply be unaware of the evidence that a given practice is actually low-value. Then there is the fear of being sued, which can prompt doctors to practice "defensive medicine" and order tests to be sure nothing was missed.

Research suggests that up to half of stress tests performed in the United States would be rated as "rarely appropriate," the AHA says. The problem with that is not only time and money wasted but that it can also lead to invasive testing that carries more risks and yet more expense.

What can be done? Actions on different levels are needed, said Dr. Vinay Kini, chair of the AHA statement writing group.

On the broad level, the U.S. health care system is designed to reward quantity — more tests, more treatments — versus quality. A payment system based on quality of care is the "way forward," Kini said, though it is complicated to define quality. Patients also play a role.. In some cases, they demand tests or treatments that are not necessary, and their provider accommodates them.

What should you do? Be skeptical. Unless it is an emergency, like a heart attack, have a conversation with your provider about any tests being recommended and be sure that you fully understand not only the reason for the test but also the risks and benefits of going ahead with it. The final decision is yours.

Is Obesity a Disease?

 

In June 2013, the American Medical Association (AMA) House of Delegates voted to recognize obesity as a disease requiring treatment and prevention efforts. A number of other medical societies had sponsored a resolution to support this idea, including the American Association of Clinical Endocrinologists, the Endocrine Society, the American College of Cardiology, the American College of Surgeons, and the American Heart Association. The National Institutes of Health had declared obesity a disease in 1998.

The AMA's decision remains controversial, since the AMA’s own Council on Science and Public Health in 2012 said that there was not sufficient data to support calling obesity a disease. So then is obesity a clinical condition or a behavioral problem?

Right now, 42% of the population of the USA are obese (a BMI of 30 or higher). Another 30% are overweight. And despite spending $3.7B on weight loss products and programs in 2020 more than 70% of us are overweight and the number keeps growing year after year. Being overweight is a risk factor for over 200 chronic diseases including cancers, hypertension, diabetes, arthritis and heart disease.

In designating obesity as a disease, the AMA recognized that it is not simply a matter of choice and willpower but of a complex set of factors that include genetics, socioeconomic status, education, medications that a person may be taking, sleep quality and more. This does not negate the timeless advice to "eat less and move more". But it suggests that it is a condition serious enough to merit the attention of doctors and other healthcare practitioners. 

The stigma associated with obesity is also an important factor. No one who is obese does not realize it. But, unlike a person hobbled by arthritis or insulin dependence, they are often shamed and told to "just stop eating so much". There is no shame in needing therapy to treat a cancer but many obese people are too ashamed of their condition to seek help.

Another mitigating factor is the lack of insurance coverage for weight loss support programs. Considering the the serious and widespread negative public health impact of obesity this may seem strange. But as long as it is seen as purely a matter of personal choice and willpower, insurance companies are reluctant to provide coverage.

No one is saying that a healthy lifestyle that includes whole, nutrient-dense foods, exercise, stress management and restful sleep is not the foundation of weight loss. But many people are not able to succeed at it. Failing to recognize it as a serious health condition, if not a disease, worthy of support and attention from insurers, doctors, the healthcare community and society at large seems likely to allow the alarming prevalence of obesity to continue to grow.

Why Does Healthcare Cost So Much?

The United States has the most expensive healthcare system in the world, and not by just a little bit. Per capita spending on medical and healthcare services in the US is nearly double the next most expensive country (Germany) and 2 1/2 times that of the UK (2018 data). Between 2010 and 2019, healthcare spending in the US rose more than 16%.

And it is not as though we are getting much more for our money. Despite significantly higher healthcare spending, America’s health outcomes are not any better than those in other developed countries. The United States actually performs worse in some common health metrics like life expectancy, infant mortality, and unmanaged diabetes. We are overtested, overdiagnosed, overtreated and overcharged but no healthier.

The fundamentals of the US healthcare system are broken. The culprits include insurance companies, government, hospitals, pharmaceutical companies, the occasional rogue doctor and us, the healthcare consumer. The result is out of control costs with no improvement in health outcomes.

As just one example, a heart bypass operation costs about $15,000 in France. In the US, with no measurable difference in quality of care or outcomes, the same procedure ranges from $40,000 to $500,000. That's right. The same procedure, with the same outcome, costs at least 160% more in the US than in France and may cost as much as 3,200% more.

Then there is the way hospitals bill for their services. Generally they have a "sticker price" that is grossly inflated. Why? Because hospitals negotiate prices with insurance companies that provide them with steep discounts and they have to make it up somewhere. Good luck finding out anything about this. The hospital and insurer generally agree to keep their discount rates secret. Your own insurer will not disclose it to you, let alone the hospital. Meanwhile, if you don't have insurance or are forced to go "out of network" for care, you pay the full sticker price, which may be marked up as much as 500%.

Even if you do have insurance, you may still be blindsided by a large "surprise bill".  This happens to about 60% of insured American who receive hospital care. A surprise bill includes sticker price charges for lab work, "facility charges", and fees for doctors you never see but who consult on your case and who may be "out of network" to you.

And then there are pharmaceutical companies. If you remember back just a few months to when Bernie Sanders was running for the Democratic Presidential nomination, he made a big issue over the cost of insulin - a vital drug for many diabetics. Many people do not know that when insulin was developed the researchers sold the patent for just $1 because they felt it would be unethical to profit from a lifesaving drug. Pharmaceutical companies had no such reservations. A 10ml vial of insulin in the US costs roughly $300. The cost in Canada for the exact same amount of the exact same drug? $30. That's right, 1/10th of the US price. One out of 4 patients in the US reports that they ration their insulin, taking less than they really need, because of the cost. Why? Just because.

Do we really need all the "care" that we get? Johns Hopkins University School of Medicine has estimated that as much as 20% of all medical services provided in the US are medically unnecessary. This includes unneeded diagnostic tests, surgeries and medication. Why? Three reasons.

First, doctors often order extra tests or procedures "just in case", to protect themselves from malpractice lawsuits.

Second, some less than ethical doctors order tests or perform procedures that insurers will pay for to make up for artificially low reimbursement rates on the services that are actually needed.

And finally, there is us, the patients. We often demand medication based on that most reliable of all sources of medical information - drug company television ads. Or demand procedures that we do not need.

The key to changing the status quo in our healthcare system is transparency.

Imagine this if you will. You are booking a flight on an airline but they will not tell you exactly where you are going or when you will get there, and you will find out what it costs at the end of your trip, when you can be charged whatever the airline feels like charging you. Sounds crazy right? And yet that is exactly how our healthcare system works today.

As we continue to debate how to provide affordable healthcare services to all Americans, it is important that we not lose track of the fact that the system itself is broken. It is not just a matter of providing insurance to more people. That just pours more money down the bottomless hole. Prices need to be transparent. We need to know what things are going to cost before we accept services, and we need to be able to compare prices among providers. We need to become educated consumers.

Here are some things you can do right now.

1. Demand upfront pricing for your medical care. And get it in writing.

2. Know what things cost. Here are some resources you can use to research costs:

FairHealthConsumer.org                                          GoodRX.com

                                       HealthCareBlueBook.com

3. Don't be hesitant to negotiate. In our healthcare system everything is negotiable. Check out RestoringMedicine.org for guidance.

4. Read before you sign. Hospital admission paperwork is mindnumbingly complex small print. Consent forms often include language obligating you to pay them 100% of whatever they charge. Cross it out.

No one is going to protect you from a predatory healthcare system. Fixing what is really broken is not even part of the discussion. So until it is, you are on your own.

Fewer Hospital Re-admissions = More Deaths

According to a study by Dr Ankur Gupta at Brigham and Women's Hospital in Boston, Medicare penalties for hospitals that readmit patients with heart failure have had their intended effect of reducing the frequency of readmission after discharge. Thirty-day readmission rates dropped from 20% before the penalties went into effect to 18.4% afterward. A whopping 1.6 point decline.

Unfortunately for the patients, this came at the cost of a 1.4 point increase in the 30-day mortality rate for heart failure patients - from 7.2% to 8.6%. Worse, the one year mortality rate rose from 31.3% to 35.3% - up 4 points - from before the program to after.

Medicare officials say that they are "monitoring" the readmission penalty program. Government healthcare at work.

Good Health is the Best Insurance

According to the 2017 Kaiser Family Foundation's annual Employer Health Benefits Survey, over the last 5 years, the number of employers offering health insurance as an employee benefit has declined from 61% to 53%. Why? Because of relentlessly rising costs. The average cost of the employer's share (not counting what the employee may contribute) of a family health insurance plan was $18,764. That's per employee.

Suppose that was your business? Could you as the owner afford to carry that sort of expense? And each year it goes up, with no sign of moderating increases. With more and more Americans chronically ill, there seems no end in sight.

The US Centers for Disease Control and Prevention estimates that 75% of all US healthcare spending goes to treating preventable chronic diseases, most of which are diet and lifestyle related. This should hardly come as a surprise.

In the US, 34% of us are obese. Not overweight, obese. Despite its many proven benefits, 79% of Americans do not meet the recommended level of physical exercise and 86% do not meet recommended dietary guidelines.

So when your employer announces increased employee contributions, benefit cutbacks or even the elimination of health insurance, reflect for a moment that the very best health insurance is living a wellness lifestyle. And that is really your responsibility. You haven't the time to live healthy? Then how will you afford to live sickly?

Deadly Drugs

Most Americans are aware that heart disease, cancers and strokes are the three leading causes of death in the United States today. They may not be aware of #4: the adverse effects of prescription medications. Every year, more Americans die from drug errors than from traffic accidents - forty people a day from prescription pain killers alone. And while nearly 40,000 of these deaths arise from behavior that might fairly be described as "drug abuse", nearly 750,000 perish is what can only charitably be called "mistakes".

To make matters worse, a recent study published in the Archives of Internal Medicine concluded that nearly 60% of the prescription medications taken by patients are not needed, and that 88% of patients reported feeling better when taking fewer or no drugs.

Let's take a look at just one type of prescription medication, the statins that are prescribed to lower cholesterol and which are the most prescribed, highest selling prescription drugs in the USA. One study published in the journal Pharmacotherapy found that 75% of people taking statins reported memory loss or other cognitive problems, and that fully 90% of them who stopped taking the medication showed rapid improvement. Other major side effects are well known and include muscle pain and weakness, neuropathy and an elevated risk of developing diabetes.

One of the less well known (among us non-experts anyway) measures of drug effectiveness is the so-called Number Needed to Treat (NNT). NNT is a measurement of how many people would need to take the drug in order for it to produce one beneficial outcome. Obviously the lower the number the better. For the popular statin drug Lipitor the NNT is 168. This means that 168 people would have to take Lipitor (for 4 years) to prevent one "cardiovascular event". Unfortunately, the risk for side effects can be as high as 1 in 10. That means 16 people will suffer the side effects so that 1 person may be helped. No doubt the fact that statin drugs produce an annual revenue of about $25 billion dollars in no way influences their popularity at the prescription pad. But to me these seem to be stunningly bad odds.

If you are taking two prescription medications a day, the odds of having a bad interaction between them is about 6%. If you are taking 5 per day, the odds skyrocket to about 50%.... 1 person in 2. With half (yes, half) of Americans taking at least one prescription drug (and nearly 1 in 5 taking 3 or more) this quickly produces large numbers of endangered people. We may be the most medicated nation on the planet.

I'll close with a personal story. About 10 years ago my mother, who was living in Florida and suffering from advancing Alzheimers disease, was no longer able to care for herself safely. As a result, she moved to California to be close to my brother. One of the first things he did was make an appointment with a neurologist, and on their first visit he took a list of the prescription medications that she was taking on a daily basis. She had prescriptions for diabetes, cholesterol, blood pressure, arthritis, degenerative heart disease and, of course, Altzheimers. Eight medications in all. When the doctor reviewed the list, she reacted with a combination of alarm and disbelief. Four of those medications were "mutually exclusive" - meaning that they had known interactions and were not prescribed together. Reducing my mothers medications to 3 per day produced an immediate, allbeit temporary, improvement in her mental and physical condition.

How could this happen? Because she was seeing four different "specialists", each of whom were prescribing medications without any idea what the others were doing. The doctors failed her, the pharmacist failed her, the insurance companies failed her, the healthcare system failed her and, to be fair, her family failed her.

The late Stephen Covey, in his book "First Things First", describes what he called "the rescue fantasy". "Most of us understand that a good percentage of the health problems we have are lifestyle-related. We live the way we want to live - little or no exercise, poor nutrition, burning the candle at both ends - and then when there is a problem we expect the medical profession to fix it. There's a pill for that."

There may be, but as more and more of us turn to medication to "fix" ourselves, we are starting to see that the cure may be more deadly than the problem.

The Diabetes Generation

An entire generation of America's children now face the prospect and dire consequences of a lifetime as diabetics, according to a report on today's NPR Morning Edition. In just 9 years, from 1999 to 2008, the incidence of "pre-diabetes" among Americans aged 12 to 19 has more than doubled (from 9% to 23%).

"That's a shockingly high figure that has dire implications to the health of this entire generation of children. This report really sounds the alarm," says David S. Ludwig, a childhood obesity expert at Children's Hospital in Boston. "It's one thing for an overweight or obese 55-year-old gaining an extra few pounds a year to develop diabetes at age 65 and then have a heart attack at age 70. It's a very different thing if the clock starts ticking at age 10. Children have so many more years to suffer from the consequences from these serious medical problems related to obesity. We're looking at the prospect of heart attack, stroke and kidney failure becoming common complications of young adulthood."

As we as a society struggle to find a way to provide affordable healthcare, "lifestyle diseases" such as diabetes will have to be addressed. To fight this trend, more and more children will face a lifetime of struggling to keep their blood sugar under control. "It requires a long period of medication use, strict diet, exercise and surveillance, all of which is quite expensive," says Vivian Fonseca at the American Diabetes Association. And that, she says, will be hard on them and society.

Listen to the full story here.

Wellness, Nutrition Cited as Key to Genuine Healthcare Reform

NPR's Weekend Edition Sunday host Liane Hansen speaks with Republican governor Jim Douglas of Vermont about that states experience with heathcare reform. He says Vermont's own state-initiated reforms could serve as a model for national changes in health care policy. Listen to the entire interview, then contact your Federal representatives and demand to know why nothing like this is even being discussed at that level.

Feel Better or your Money Back?

Not exactly. But if you are following Washington's "healthcare reform debate" at all you can be forgiven if the whole thing sounds more like "health insurance expansion". Proposals for, or even discussion of, actual changes to our broken healthcare delivery SYSTEM are more scarce than modesty at the Academy Awards. How about some innovation in the actual provision of medical services?

Here's an interesting idea from a PricewaterhouseCoopers study reported in the Colorado Springs Business Journal. What if instead of paying for how many different procedures a doctor ordered, we paid instead for the outcome? The RESULT of their treatment. Is it practical? Would it lower healthcare costs while maintaining or improving quality? I don't know, but it seems to me that simply adding more and more people to our unsupportably expensive system surely wont.