A Tale of Two Health Systems

Kim BellardThe U.S. healthcare system, it must be admitted, is pretty good at some things. If, for example, you have a heart attack, need an organ transplant, or want to undergo the latest cancer treatments, it's hard to do much better than in our system (aside from the pesky problem of paying for that care).

Otherwise, not so much.

If you are in generally good health with only intermittent interactions with the healthcare system, you probably view those encounters with both reluctance and some frustration. If you have chronic health issues, you are forced to regularly navigate the byzantine maze that our healthcare system has become; either you learn to muddle your way through, or you die trying.

We have a one-size-fits-all healthcare system that, unfortunately, doesn't fit most of us. The facts are well known but not well appreciated, at least not in terms of the "design" of our healthcare system. As illustrated in the chart below, a small percentage of people account for most of our healthcare spending. Most of us contribute very little to the nation's health spending. So where is the healthcare system that focuses on the top 10%? And how is it any different from the system for everyone else?

It's not, and that's the problem.

People in the top 10% need help. They need experts who can help them navigate that byzantine maze. Many health plans have "care managers" who are supposed to be those experts, as do many hospitals and some physician practices. But usually these are telephone-based, only touch base periodically, and have lots of other people on their rosters.

Few of them would be at your side if you had a health crisis, especially at night or on the weekend. Few of them would know in real-time. They're not their holding your hand in the ER, or watching your diet.

We spend two-thirds of our money on only 10% of us, but we can't afford to give them intensive attention? Seriously? Instead, we have created a health system that, for all intents and purposes, tries to pretend that we are all in that 10%. It tries to treat us equally, that is, on average: the sickest of us do not get enough attention, the healthiest of us get too much.

No wonder our doctors' offices are so crowded and our appointments last only 10 minutes.

We need a different health system for the majority of us, if only so that we can devote the necessary resources to the people who need to use our health care -- aka medical care -- system the most.

My vote is for a public health system.

You know, public health. Like clean water. Like vaccinations. Like safer food. Like reducing smoking. It includes a variety of efforts that, intentionally, do not usually look much like medical care but which have drastic impacts on health and longevity.

In a recent article in The Upshot, Aaron E. Carroll and Austin Frakt make the case for why we should spend more money on public health. As they detail, we spend very little -- depending on what you count, as low as $10 billion and as high as $100 billion or so, either of which is basically a rounding error in our overall health spending -- but which often have dramatic paybacks.

After all, they note, much of the large increase in U.S. life expectancy in the 20th century came from public health investments, not more or better medical care.

Let's think about it:

  • Our dismal maternal and child mortality rates are public health crises.
  • Our opioid epidemic is a public health crisis.
  • Our diabetes and obesity epidemics are public health crises.
  • Our lack of exercise is a public health crisis;
  • Our gun violence epidemic is a public health crisis.
  • Our vehicular death problem is a public health crisis;
  • Our homeless and suicide problems are public health crises;
  • Our "food desert" problem is a public health problem;
  • Our increased consumption of packaged food is a public health crisis;
  • Our lack of enough safe, affordable housing is a public health crisis.

I could go on, but hopefully you get the point. Think of your "favorite" national or local health problem and think hard about if it is a medical issue or if it is, at heart, a public health issue. For example, a recent BMJ study concluded:

It is time to shift the public health message in the prevention and treatment of coronary artery disease away from measuring serum lipids and reducing dietary saturated fat. Coronary artery disease is a chronic inflammatory disease and it can be reduced effectively by walking 22 min a day and eating real food. There is no business model or market to help spread this simple yet powerful intervention.

We need to make public health that model.

We're talking more about the importance of the social determinants of health (SDoH), and that is good, but my fear is that we're going to try to sweep them into our medical care system. We medicalize too much. We look to medical professionals and medical organizations too much for our health.

But, as Howard Gleckman reported in Forbes, a new survey by Leavitt Partners:

...shows that while physicians generally agree that assistance with housing, transportation, and nutrition is important to the health of their patients, most doctors feel they are not responsible for helping them get these services

He adds that, from his own experience: "Physicians feel they do not have the time, knowledge, or interest to guide their patients to important non-medical assistance."

Let's no longer try to pretend this is what they should (also) do. Mr,. Gleckman didn't go quite as far as I am in calling for a public health system to help address these needs, but I like to think he might agree.

We usually talk about a two-tier healthcare system as being a bad thing, and it is when it refers to people not being able to get necessary care due to socioeconomic factors. But it may not be if we design each system to most effectively target the right population, and know who needs to use which when.

We need to stop view public health as a boring, not glamorous, small part of our healthcare system, but, rather, as the bedrock of it, and of our health.