Our health is worsening at a time when medicine has never been better

With little notice, UnitedHealth released a major paper recently considering diabetes in America.

First the bad news: a large portion of our population either has the disease or is pre-diabetic.

Now, the really bad news: diabetes and pre-diabetes rates are going to soar in the coming decade, according to the analysis, in part driven by the obesity crisis.

I’ll return back to the study in a moment, but it underscores a paradox: medicine has never been better; our overall health, however, is worsening.

Indeed, after seventy years of staggering medical progress — whereby medicine has evolved from passive care to miraculous cure — we seem to have entered into a new age, one in which personal decision will increasingly influence our health and the cost of our health care.

The problem is that almost no one in Washington seems to have noticed.

On this, we can all agree. Medicine has been transformed in the past decades.

Pre-1941: Prior to 1941, the state of medicine is well represented by Luke Fildes’ famous etching.

The doctor looks august, thoughtful and pensive. But notice what he isn’t doing — much of anything. Frankly, there isn’t much difference between the passive approach of physician here and the distraught mother in the background. Outside of thyroid supplement and insulin, medicine offered little but empathy to its patients.

The Modern Era: On February 12, 1941, the era of modern medicine was ushered in when the first clinical use of penicillin. Medicine went from passive care to miraculous cure. The doctor in that famous etching got off his chair and started to do things.

The latter part of the twentieth century saw one discover after another. Steroids, antipsychotics, open heart surgery, kidney transplants — all within a dozen years of penicillin’s first clinical use. The pace of change has been extraordinary.

Today, medicine has never been so advanced. Surgeries are done on fetuses months before birth; death by cardiovascular disease has fallen by two thirds in fifty years; diseases that were once death sentences, like childhood leukemia, are curable.

The Age of Preventable Illness: But if medicine has never been so advanced, the actual health of Americans is far less robust. The Era of Modern Medicine has given way to the Age of Preventable Illness. Americans have embraced a culture of extremes: too much alcohol, tobacco, drugs, and food, and not enough exercise and restraint. American leads the way in medical innovation, winning more Nobel Prizes in Medicine than all other countries combined. We also lead the world in obesity, and have the poor life expectancy statistics to show for it.

The consequences of the culture of extremes are unfortunate.

Indeed, as others have argued, including Dr. Steven Schroeder in the New England Journal of Medicine, we have reached a point where traditional causes of premature death — environmental exposure or lack of access to health care — are modest. What isn’t modest? Dr. Schroeder argues “behavioral patterns.”

The statistics are discouraging: 1 in 5 smoke; 3 in 10 are obese; 1 in 3 don’t even take their prescribed medications for illnesses like hypertension.

Which brings us to that study on diabetes.

In “The United States of Diabetes,” researchers at UnitedHealth estimate the rising cost of diabetic care in America. Diabetes has no single cause but, with profound weight gain, it’s clear that our obesity problems are causing diabetes to become ever more common.

This new study estimates that health spending associated with diabetes and pre-diabetes is currently $194 billion a year (7% of total U.S. health spending). That cost is projected to rise to $500 billion by 2020, as the percentage of people with diabetes and pre-diabetes rises to 52% of the population.

Interestingly, taxpayers are the ones who would be most on the hook for diabetic care and the treatment of diabetic complications, since the majority of diabetics will be on Medicare and Medicaid.

A few thoughts on the UnitedHealth study:

1. Washington doesn’t get it. For much of the last two years, Washington politicians of both parties have debated how to reign in healthcare costs. But as obesity rates rise and the resulting illnesses like diabetes become ever more common, we stand little chance no matter what happens to ObamaCare.

The larger debate is not about the IPAB or health-insurance exchanges or Medicaid expansion, it’s about health.

2. The ObamaCare model is dated. For Democrats, the view of healthcare is dated — they see illness as an act of God, leaving patients stricken with disease that could not have been avoided. Not surprisingly, then, ObamaCare seeks to divorce people from the financial consequences of their health decisions — regulating insurance to treat people equally regardless of age or illness (community rating), offering many no-deductible services, mandating the coverage of other services, and sweetening the deal with heavy subsidies.

Let’s be clear: a patient with Schizophrenia shouldn’t be punished because his father and grandfather had the disease. But many illnesses are preventable. Rather than encourage health, ObamaCare seeks to socialize the costs of bad health.

3. Public health efforts have been weak. In the past, governments looked to “knee-jerk regulation.” Anti-obesity efforts — well meaning as they are — represent “feel-good regulation.”

Calorie listings, salt reductions, trans-fat bans. These efforts offer little potential of success.

Consider a NYU-Yale study that surveyed 1,100 fast food customers in poor New York neighborhoods. While people claimed making healthier choices when given the calorie-count information, researchers found that customers actually ordered more calories, not less.

The issue isn’t ignorance (does anyone really order a Big Mac and assume it to be a healthful meal?) or the plague of one bad ingredient (like salt), it’s a culture of excess. Policy prescriptions need to address the larger problem.

4. Conservatives need more to say. The conservative response to date has been anemic. With rising rates of obesity and diabetes, many have been happy to attack meddlesome liberal efforts, without offering anything in its place.

Take as an example Sarah Palin. Speaking in Plumsteadville, PA, the former VP candidate criticized the Pennsylvania’s State Board of Education’s plan to limit sweets in classroom parties. Earlier in the day, she had brought cookies to a classroom. She explained:

I heard there’s a debate going on in Pennsylvania over whether public schools were going to ban sweets. I wanted these kids to bring home the idea to their parents for discussion: Who should be deciding what I eat? Should it be government or should it be parents? It should be the parents.

The issue is more complicated than portrayed by the media, and Ms. Palin isn’t entirely wrong. The State Board of Education is considering pushing all children’s celebrations to one month and requiring that there be non-sugary food options at classroom parties.

It’s difficult to find this compelling (January kids would then celebrate their birthdays in, say, June?) or particularly practical (will children in large numbers opt for a medley of vegetables over the birthday cake?). And involving parents is reasonable enough.

But Ms. Palin’s attack is also paper-thin. Yes, the Board of Education seems to have identified a real issue and matched it with a bureaucratic answer, but what to do about the larger issue? Conservatives seem happy to attack the “nanny state” (to quote Palin’s Tweet) but offer little in its place.

And there is a conservative response on this issue. At a time of rising rates of obesity, we should emphasize physical education in our schools and better food in their cafeterias. Washington spends billions subsidizing big business and bad health choices through agricultural subsidies — it’s difficult to ever see the justification for this, but, at a time of record deficits, there is none. Health insurance needs to move from a model of sick care to one that promotes wellness. And, finally, we need to practice more restraint in our eating habits.

Conservatives have long argued for the need for personal responsibility, bemoaning fatherlessness and divorce. It would be a pity, then, to see the movement fall into obesity nihilism.

David Gratzer is a physician and senior fellow at the Manhattan Institute. He is author of The Cure: How Capitalism Can Save American Health Care.

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  • Donald Green MD

    I’m afraid Dr. Gratzner doesn’t get it either.

    I’ll just take him on with #2 above. He forgot seniors that make up almost 40% of our health care costs. Does he want to prevent old age too?

    Further the health care system depends on taking care of sick people to sharpen its ability to care for our “healthier citizens” if by chance they happen to fall ill. I also believe it is the sick who help train doctors to become skilled care givers.

    We all benefit when a medical system takes care of patients. Since it is unpredictable who will need care with any certainty we all benefit by sustaining the system.

    Insurance works by having the largest risk pool when it is paying for the same basic services. Charging excessively differential rates based on problem-ridden underwriting principles will shift even more cost onto subscribers.

  • http://www.hopestreetgroup.org/index.jspa Joy Twesigye

    Health care delivery is about optimizing health as well as treating and managing illness and disease.

    It seems as though you are railing against the tools of government (public services announcements and regulations for example) that have been used thus far as being useless—while asking for more public services announcements and regulations:

    “At a time of rising rates of obesity, we should emphasize physical education in our schools and better food in their cafeterias.”

    “Health insurance needs to move from a model of sick care to one that promotes wellness. And, finally, we need to practice more restraint in our eating habits.”

    Personal responsibility can be engendered in a variety of ways. We would like to promote the introduction of financial incentives, where possible, to increase the likelihood that preventive care will occur. But we would also like to provide the tools that help consumers manage their own health and would like those tools informed by the people who use them. In addition, we recognize that good nutrition and lifestyle are not always obvious so we believe that nutrition information combined with affordable nutrition should be pursued. Finally, access to relevant information has to be creative, interesting, and tailored to the audience.

    We lay out specifics on how to empower consumers to take personal responsibility for improving their health through education, interactive tools, and incentives at http://www.hopestreetgroup.org/docs/DOC-2480

  • Dorothy Green

    We need to change our eating culture. We already know that the culprits to most chronic preventable diseases are sugar, salt and bad fats. We only had the salt from seafood and some from plants – maybe about 500mg, we only had sugar in fruits, and honey or other natural sources, we ate meat from animals who ate grass. That’s what formed our DNA.

    Even though 1 in 5 people still smoke tobacco it is a whole lot better than 3 in 5 as it was prior to the campaign to collect revenue from this addictive substance and send a powerful message.

    Since this model worked so well on tobacco why are we so beholden to Big Food and choice (like 275 kinds of cereal- most of which is not nutritious) as we were to Big tobacco.

    1. Stop the agriculture subsidies that are used to make food unhealthy and cheap.

    2. Accept that it is part of the human condition that some become addicted – especially to the sugar, salt and fat in food.

    3. Tax the addictive substance and send the message.

    4. Everyone needs to be in the insurance pool to help pay the cost of real disease and health problems (like down’s syndrome) but not to subsidize the addictions to food or tobacco.

    4. Stop the pervasive media ads from fast food companies that promote overeating. Other countries have.

    5. There are many volunteer or community efforts doing the prevention but these are not enough.

    Yes, seniors are the highest cost and probably will continue to and they have the most chronic preventable diseases.
    Seniors will not be exempt from a RISK (reduction in sickness kitty) tax on the sugar, salt and fat they consume. Noone will. But think about it. Those who consume the most will pay the most toward their risk of getting a chronic preventable disease.

    Seniors (I for one) did not know about sugar, salt and fat addictions until I was a senior. I am sure I have suffered some damage to my body because of it, but fortunately I now know and do not have any chronic preventive disease. Also, knowing what I know about healthcare, I have a living will and will be really pissed if someone tries to treat me when my brain is dead nor do I want to pay for the care of others whose brains have died. This should be a choice, up front, stated by the person and paid for in advance. Here is where much of the senior costs goes.

    Sarah Palin doesn’t seem to recognize balance or where things have a place and others don’t. Our eating culture is largely dictated by Big Food not the government and many parents are either addicted to sugar, salt and fat themselves and past this onto their kids and or have no control once they are out the door.

    The healthcare reforms have a place but they will not bend the cost curve – only changing our eating culture will!

  • doctor

    Interesting “food for thought”. Unfortunate trend is that as medical capability to treat grows (albeit at a tremendous dollars and cents cost) people become more dependent upon it. I don’t have any simple answers, and not much optimism.
    -” Our eating culture is largely dictated by Big Food not the government .” Big disagreement here. Agriculture corn subsidies (i.e. “The Government”)=High Fructose Corn Syrup=Obesity crisis. Don’t count on government regulation or decision making to make things better.

  • NurseKicko

    I think the cure is education all around. We are as screwed with the diabetic population’s cost as we are with the national economical debt problem. It’s a case of too little too late. We don’t train our population to eat smart, live healthy, or even understand the contents and workings of their own bodies. You cant put out a fire at the tip of the flame, you have to aim for the base. I say we change the educational system starting with kids. Push back cellular biology until junior high school and introduce the macro world of science… the human body. Physiology, anatomy, and nutrition sciences at a younger age would change the way the population understands their own health and then people (not the white house and tax payers) could take initiative and responsibility for their own health. It wont solve the problem for now, but it will save the future. P.S. If you are interested in the stock market, it might be a great time to invest in insulin manufacturers and accu-check makers…

  • http://www.littlepatientbigdoctor.com Haleh Rabizadeh Resnick

    I agree.

    Good health can’t come out of the medicine cabinet alone. It is a lifestyle decision – everything from nutrition to exercise to our emotional, psychological and spiritual well being need to be considered.

  • Brenda

    Everyone always oversimplifies things….personal choice or responsibility, lifestyle changes, blah blah blah. But every family is not “Leave it to Beaver”. There are many households dealing with major issues: domestic abuse, addiction, poverty, people working long hours or even two jobs and so much sit down type work out there, spouses at war, business travel, those caring for ill or handicapped family members (better or longer survival rate due to modern medicine), depression, on and on. All these things make it very diffcult to buy and eat all the right things, get to the gym, or whatever. What people should do, want to do and what they can do mentally and physically are entirely different things. And yes they do add fatting fillers to food to make them go farther and they still overcharge for them.

  • Dorothy Green

    Every possible solution is necessary – individual, public and private to start making dramatic changes in our lifestyle culture (eating, exercise, addictions) Many efforts have started as pointed out by respondants – also check out TED talks – food – Ann Cooper, Jamie Oliver, Blue Zones, Dan Barber, Alice Waters, Michael Pollan etc. The impact is palatable but very, very slow. Even our government has finally come out with more reasonable nutrition guidelines. There are a number of but how easy are they to follow and will the people NurseKicko talks about even consider changing?

    I say use the tobacco model (revenue, message on pkg, education, stop subsidizies, stop ads) for processed/added sugar, fat and salt because it worked and continues to work as well as any effort can to lower use of this substance ( 65% to 20%. Futher, I don’t think we can wait – there is a direct impact now on our economy (primarily through healthcare costs), energy consumption (think corn fed cow meat and dairy, vegetable oils), waste and I am sure a lot more.

    Once it is accepted that these substances are potentially addictive (Dr. Kessler – The End of Overeating) it is easier to make real progress. It can’t be the only change – but it can offer the message (education) on packaging that supports the information provided in the NUTRITION FACTS about the RISK of these substances. RISK Revenue can be used for education and all the other necessary efforts toward a healthier country.

    The battles with Big Food will be very, very, difficult, just as fighting the tobacco industry but I will not say – it’s too late, or can’t be done. I am ready and have signed petitions to this end.

    Thank you all putting up with my redundancy in this message. I have developed a model for the RISK (reduction in sickness kitty) I talk about.

  • http://www.thepatientfactor.com The Patient Factor

    Diabetes and obesity rates are rising here in Canada as well. There is little incentive for people to adopt healthier behaviors when they are insulated from the true costs of their medical care. Things are unlikely to change until individuals, not third-party payers, assume the role of customer and start paying directly for their own medical care.

    • doctor

      Well put. Sorry similar problems north of the border.

  • http://www.dom.edu/wellness Elizabeth Ritzman

    Well, since agrigultural subsidies began, we have been a food culture that have been driven by business decisions of food manufacturing and distribution giants. Basically, they control food access and pricing. Additional fat and sodium support an addictive reaction by the human brain; more food is better – and that works well from a business standpoint.
    Monsanto and subsidiaries have moved to prevent even the most basics of gardening – read the fine print on the tomato start you buy and you’ll see you are forbidden from propogating (preserving seeds for next year or self hybridizing) it. So, I guess that means an end to gardening eventually.
    As long as corporations are so highly entitled, these health problems won’t be easy to fight and public health efforts will be up the proverbial creek without a paddle.

  • Molly Ciliberti, RN

    I am afraid you don’t get it either. Democrats don’t believe that horse pucky you admonish them for. That is your personal delusion or maybe the delusion of Republicans. The only problem with the new Healthcare legislation (calling it Obamacare says more about you than it; it says you are a conservative Republican with a closed mind) is that it didn’t go far enough. My physician husband and I want universal healthcare like the rest of the industrialized countries. But that would scare you silly. I find the title of your book, “The Cure; How Capitalism Can Save American Health Care.” telling. Capitalism in this country is not really a free market with subsidizing for all sorts of so called free markets. It was capitalism that crippled healthcare with insurance companies with their only real goal in life, insuring that our money got into their pockets. Once profit became king, healthcare declined and the poor are always the first to get clobbered. The qualities of a country shine the most clearly by the way they treat their poorest members.

    • MedPeds Doc

      Are you and your physician husband willing to pay 70% of your income in taxes and fees for universal healthcare to exist? Then everyone will have care but no one, including the poorest and sickest, will have accountability for their actions. Anyone could go to the ER 365 days a year if they so desire with no disincentive. Everyone can call 911 for a ride to the ER to treat their cold. Unfortunately, human nature is such that we humans seem to take advantage of all of these entitlement programs. Look at these very educated teachers in Wisconsin who are being made to put half of the money into their pensions and 10-12% into their insurance costs. You would think the world is ending! I am self employed and fund these benefits for myself 100%.

      We should expect bad things to happen to us and deal with the consequences as best as possible; we should expect humans to make mistakes and not hold them legally responsible even if we are harmed; we should expect to pay off our houses as fast as we can and save for ourselves to live off of when we retire; we should expect our families and not our government to care for us in our old age if we are unable to care for ourselves; we should expect there will always be rich, poor, and those in between; we should work daily to improve the life of the poor and less fortunate through very simple projects/acts done locally and outside of the government umbrella. Our government has worked to defeat the human spirit by enabling people to need the government. More personal responsibility and less government would take us a long way.

  • Dorothy Green

    I didn’t read the book you refer to – glad I didn’t. However, I did read, analyze and discuss in classes T.R.Reid’s – the Healing of America – 2009 and Paul Starr’s award winning The Social Transformation of American Medicine, 1985. Both show the failings of the US present non-system health care and the positives of other advanced countries. Yeah, we need a universal healthcare something – be it with non-profit insurance like Switzerland or say, single payer like Canada. As long as we get rid of for-profit health insurance ASAP, introduce other healthcare reform in the bill AND use the RISK tax as I suggested, we can bend the curve of costs. They all need to be done. Health care reform without RISK will ot bend the curve. We are the world’s leader in obesity/overweight etc, healthcare cost/capita. Doesn’t make economic sense.

    Thanks for bringing this oversight to my attention.

  • imdoc

    “Diabetes and obesity rates are rising here in Canada as well. There is little incentive for people to adopt healthier behaviors when they are insulated from the true costs of their medical care. Things are unlikely to change until individuals, not third-party payers, assume the role of customer and start paying directly for their own medical care.”

    Interesting comment. In the U.S. we are being sold a bill of goods from the big government advocates (yes, the same who brought ag subsidies) that single payer will solve all this

    • http://www.thepatientfactor.com The Patient Factor

      In my home province of Saskatchewan (estimated population of 1,049,700) there are currently 26,880 people waiting on lists for surgery. The Saskatchewan government recently agreed to pay $40 million for another 5,550 surgeries which means that at least 21,330 patients will be left waiting. As it is illegal for patients to pay directly for any publicly funded medically necessary services, their only option is to wait on lists or leave the country. Our province relies heavily on foreign doctors (46% in 2009) and all of our doctors are paid by the government through our single-payer government insurance system. In short, our provincial government decides what type and quality of medically necessary services patients will receive and how we will access them. It’s time to return health care back to its rightful owners – patients and their doctors.

      • doctor

        Again, important comments from north of the border.

      • gzuckier

        I don’t actually have any dog in this fight, but

        Median Wait Times by Specialty
        Surgery Performed 01-Jun-2010 to 30-Nov-2010
        All Cases Non-Emergent Cases
        Specialty Cases weeks Cases weeks
        Cardiac 799 0.4 584 0.7
        General 7,740 1.6 5,537 3.3
        Neurosurgery 823 1.7 615 4
        ObstetricsGynecology5,617 3.3 4,343 6.1
        Ophthalmology 6,880 7.1 6,724 7.4
        Maxillofacial/Dental 1,853 10.7 1,839 10.9
        Orthopedic 7,138 6.6 4,796 16.6
        Otolaryngology 2,523 9.6 2,427 10
        Plastic 1,390 3.3 1,071 10
        Urology 2,449 3.6 2,073 4.3
        Vascular 656 0.6 428 3.3
        Other 359 1.1 285 1.7
        Overall 38,227 3.9 30,722 6.6
        Other specialties include Anesthesia, General Practitioners, Pediatrics, Physical Medicine and Rehabilitation, Psychiatry, and Rheumatology.
        51 records with invalid wait times are excluded.

        I don’t know if I could get nonemergency cardiac surgery within 0.7 weeks here in the US.

  • gzuckier

    “Earlier in the day, she had brought cookies to a classroom. She explained:
    ‘I heard there’s a debate going on in Pennsylvania over whether public schools were going to ban sweets. I wanted these kids to bring home the idea to their parents for discussion: Who should be deciding what I eat? Should it be government or should it be parents? It should be the parents.’”

    Yes. Specifically, whichever parents of a kid in the classroom have the most lax attitudes towards what their kids eat should be free to feed your kids whatever they wish whenever they wish. Let the whole class chow down on the deep fried twinkies Mrs. Blobwich sends in with little Tiny at every opportunity. It’s the American way. I’m pretty sure it’s in the Constitution. Or the Bible, maybe.

    And fie on those kids with food allergies and sensitivities, they’re just jealous of our freedoms.

  • http://journaltowellness.com Kathleen Clohessy

    I am appalled that not one medical “expert” of the dozens who, like the author, rant about America’s “obesity epidemic” has discussed the problem in the context of the medically created epidemic of antidepressant use.

    Two facts that are consistently ignored in discussions such as these are directly related to this issue.
    First: Antidepressants are the most commonly prescribed class of drugs in the United States. According to a government study, they are prescribed more than drugs to treat high blood pressure, high cholesterol, asthma, or headaches. This data, was collected by the CDC in 2005, however, there is no evidence to suggest the trend has changed in recent years. Quite the opposite, given the plethora of antidepressants available today, one might assume that it is more true than ever.

    Second: It is an indisputable fact that antidepressants of all kinds-tricyclics, SSRIs and SSNRIs as well as drugs like Wellbutrin and Buproban for smoking cessation-make people FAT. What makes this simple fact worse is that not even nutrition experts know why these drugs cause such consistent weight gain, nor do they have a clue how to treat or prevent obesity related to antidepressant use.

    While this is not the forum to discuss why the epidemic of antidepressant usage exists, I believe it is time for the medical profession to ask why so many doctors continue to prescribe these drugs that are so questionably effective for depression and so definitely bad for America’s collective waistline.In light of America’s obesity epidemic and the enormous number of health problems obesity creates, it seems that this one factor has been glossed over long enough. While pointing the finger at America’s culture of excess is certainly appropriate, the medical profession must certainly take responsibility for doing very little to keep it under control as well.

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