Manufacturing Disease, Episode 1
This is the first in a series of blogs about how modern America’s (and the modern world’s) healthcare epidemics are simply the end result of a series of lies perpetrated upon us by politicians and the corporations that control healthcare.
One hundred years ago, the First World War came to an end. Over the ensuing decades, we would see the end of epidemics like polio, tuberculosis, and typhoid fever. Life expectancy would skyrocket, largely thanks to reductions in infant mortality. Note that the major genocides of this period, notably the Ukrainian Holomodor and Mao’s famines, were the result of autocratic systems in which individuals had little freedom in how food was produced and even less freedom in how it was distributed. Healthcare and food production are similar in many respects, and it is no coincidence that, no matter to what degree your healthcare system is “privatized” or “socialized,” the more “centralized” your system is (in the hands of unaccountable, monopolistic corporations or unaccountable, monopolistic socialized healthcare systems), the worse the outcomes it delivers.
After decades of rapid medical progress, we now face declining life expectancies despite practically a quarter of our expenditures going toward healthcare, not to mention far more of our money (both in the US and globally) being funneled into biomedical research.
Pre-existing conditions are what happened. Yet the term “pre-existing conditions” is nothing but Orwellian double-speak for “I didn’t have this yesterday, my grandmother never heard of it, and now all of a sudden, it might kill me.”
Let us be clear about what pre-existing conditions are and what we must do about them. Pre-existing conditions are reversible medical conditions that have arisen due to changes in our environment, thanks to our love affair with technology. Technology has enabled our rise to power over our planet, but it has also enabled our downfall biologically. Whether you want to blame meat, tofu, cell phones, or sugar for modern disease epidemics, there is universal recognition of the fact that we now face chronic diseases that are the result of diet and lifestyle changes — changes that have only been enabled by technology.
We banished paleolithic diseases with technology, only to fall into neolithic diseases. Treating paleolithic diseases with neolithic technologies is the most fun I have ever had. This is where we “save lives.” Treating neolithic diseases with neolithic technologies is like trying to stop water from rolling down a hill. This is why physicians are burning out and patients have never been more unhappy with their healthcare. Diabetes, obesity, autoimmune and allergic diseases, heart disease, stroke, Alzheimer’s disease, and practically all forms of degenerative illness are clearly linked to our use of technology. This is why scientists study the Amish, the Hazda, the Massai, and people in “developing” nations to determine what environmental factors determine our health and wellness.
The affordable way to fix our modern epidemics is clearly to use technology more responsibly. Insurance instruments always balance what you want to do against what will cost the insurer in the case of a “blow up” — a huge event resulting in a loss. Why doesn’t your health insurance company, then, send you regular notices in the mail to inform you of how to better behave yourself? Why don’t they tweet out helpful hints and tips to try to engender better health among the public?
Health insurance in this country has turned into the biggest scam and fraud in history. Our system most closely resembles a fascist healthcare system, one in which corporations and the state collude to impoverish the people while simultaneously robbing them of their freedoms.
How did this happen?
More importantly, how can we fix it? How should health insurance truly work?
Before tackling how to provide insurance, we need to dispense with the lies that have been used to justify the current system. How I would provide health insurance flies in the face of how it is sold now and is probably illegal in more ways than there are dollars on K street to bribe politicians inside the beltway. These lies can generally be distilled into five key categories.
1. “People need healthcare to be healthy.”
Tell this to rural African tribesmen who do not have a name for diseases like “Alzheimer’s” or “allergies.” Tell this to the Amish, who, while everyone around them are developing allergies, maintain low levels thanks to their pre-modern lifestyles. I could go on ad nauseum. The human body can heal itself and, more importantly, is designed to interpret and behave in its environment to maximize its wellness. This stands in stark distinction to your car, which requires maintenance, inspection, and occasional replacement of a part. You cannot trade-in or upgrade your body.
If you have a problem with this idea, then you have a problem with Darwin. His central argument, which is the bedrock of modern biology (and, quite independently, is a simple logical conclusion you can verify based on data you can collect staring out your window), is that organisms adapt over time to their “conditions of existence.” Your conditions of existence make you extremely vulnerable to things like infections, food poisoning, blood loss, and envenomation by things like scorpions and rattlesnakes. This means that your physiology is optimized to prevent death by these causes. Just a single event, such as a snake bite, an amanita mushroom in your soup, or the bite of a mosquito carrying malaria, can kill you. This means that your physiology is optimized to avoid these problems or be able to deal with their consequences 100% of the time.
Contrast this with the risk of death by eating a single candy bar, which is virtually zero. Yet we have epidemics of diabetes and obesity that are effectively a slow-death by candy-bar — let us call it “death by a thousand candy bars.” You therefore have little in the way of innate immunity against the bad idea of eating candy bars. You think they are delicious, until other people tell you about what happened to other people who ate too many of them. Healthy people only occasionally need medical care, usually for accidents.
Regardless of how many candy bars you eat, as you age, you grow weaker and more vulnerable to disease. Eventually, you suffer a “terminal event.” Typically, people fight their diseases, which is what we call healthcare. Yet notice that healthcare is not required to be healthy — it is required to diagnose causes of illness and to frustrate death. This is what healthcare today excels at, yet the odds of these terminal events are entirely independent of how much healthcare you have had or will receive — those odds depend upon how you have lived your life and even on events that transpired before you were born.
The solution to this problem is therefore to create a good or service that provides people with accurate information that will prevent disease. This is what health insurance should do, but notice that your politicians have carefully regulated it so that it cannot, and therefore does not, provide this. More on this in the third blog post of this series.
2. “Healthcare is too expensive and will always be too expensive.”
Healthcare is only expensive because the incentives within the system are improperly aligned. This is because you want bad medicine. You want your doctors to treat you to death. How could you be so stupid? Because you only see the upside of more tests and procedures — you do not understand the magnitude of risks and benefits to more tests and procedures. You want to “make sure” that you don’t have heart disease, so you want a stress test.
- Explain to you why your odds are incalculably low.
- Order a stress test.
Arguing with patients is time consuming, so when presented with a clear preference by patients, I have observed that most doctors will go along with what is being requested. There are a few exceptions to this.
- The procedure won’t make the doctor money.
- The doctor has already done some kind of testing that demonstrates the odds are incalculably low.
This is because of how malpractice law works in the United States. Doctors who test more can always say, “but I ordered the test! I didn’t ignore the patient’s complaints!” This saves the doctor time, so that he can see more patients, and reassures the patient, who will think of the doctor as someone who cares about them. Patients tend not to sue doctors who they like. I easily order, or see my colleagues order, thousands or hundreds of thousands of dollars worth of unnecessary tests every single week. Multiply that by dozens of doctors in dozens of hospitals in 50 states, and you end up with an enormous bill.
This is not even to mention the fact that, as we increase the number of tests we do, we increase the risk to patients. Say that for every 5,000 CT scans we perform with IV contrast dye, we cause one person to go into renal failure and require dialysis. People on dialysis have a life expectancy of 5 years. People on dialysis automatically qualify for Medicaid, and their dialysis bills alone are approximately (last I checked) $88,000 per year. When you factor in how often then end up in the hospital and how much we spend taking care of them in the hospital, many dialysis patients become $250,000-a-year projects. If they each live 5 years, that a cool $1.25 million, just in the last 5 years of life. The first industry who should take issue with over-testing and over-treating is not the patient, who is poorly equipped to understand Bayesian statistics, nor the doctor, whose incentive is always to “do more,” but the insurer.
I am not arguing that the insurer should “play doctor.” Rather, the insurer needs to explain to the patient “here is where more testing and more treating will get you killed and drive up your premium.” Frankly, if people want to buy bad medicine, I see no reason to stop them. After all, insurers can be wrong and, besides that, you may have a strong family history or occupational risk that your insurer does not know about. Insurers can always sell you more insurance — they will be only too happy to do so.
The solution to this problem is allowing people to negotiate prices and compete with one another in providing better goods and services within healthcare. If you take issue with the idea that competition drives prices down, then explain to me how every year smart phones today are better, faster, and stronger than they were the year before, and yet prices are stable or even lower. Why doesn’t healthcare work the same way? If you answered something along the lines of, “because politicians are morons whose morals are for sale,” then you get a gold star.
3. “Everyone needs lots of medical care at some point.”
This is nonsense and one of the most pernicious fallacies used to con the public into supporting bad ideas. We know today that fake food, fake light, fake air, fake water, “bad” habits like smoking, promiscuity, and drug use, flying too much, and so on and so forth, are all risk factors for diseases you do not want. We also know that the downsides of spending too much time in nature — the occasional injury, various infections, broken bones, and so on are exactly what nature has built you to withstand. The average person who shows up to the ER with paleolithic medical problems like spider bites and broken bones can get all the care they need often in a single day, or within the span of two or three follow up appointments. This means that, if you avoid fake, modern crap that undermines your biology, and you live a life connected to nature, your healthcare costs will be low.
When we look at healthcare expenditures on a single patient compared to their outcome, we notice that this is not a linear relationship. Ten dollars does not get you ten more minutes of life. A ten dollar antibiotic is often all we need to cure someone of a simple case of pneumonia that could have killed them. No chest x-ray, blood testing, or specialists are needed. The probability of contracting pneumonia depends upon many factors, which we might summarize as your “vitality.” This is why young people get sick all the time with bronchitis and “colds,” but rarely end up hospitalized. This is also why old people can have a cold and feel a bit “under the weather” one day and be in the ICU the next.
If you are the doctor treating someone in your office or an urgent care for what could be pneumonia, you do a simple calculation in your head about the odds of this patient going home and getting sick enough to require hospitalization. If the odds are bad, you tell them they need to go to the ER. If the odds are good, you send them home with antibiotics. So if someone is on 30 medications and has dozens of diseases, from obesity to diabetes to hypertension, you cover your ass and send them to the ER. No ifs, ands, buts, or further conversation.
As the patient’s complexity and level of sickness increases, the system begins to spiral out of control in adjusting for inherent, underlying risks. Once you are admitted to the hospital, you end up getting a CT scan, because your doctor needs to cover his ass and Medicare will pay for it. They end up finding a few nodules that need follow up imaging to make sure that they aren’t cancer (they probably are not). For every few thousand people who get this kind of imaging, one or two will develop lung cancer thanks to the extra radiation. Once they are admitted to the hospital, they get started on everything from tylenol to stool softeners, because this keeps the doctor from being called in the middle of the night with questions like, “The patient in room 306 is constipated and wants a laxative.” Likewise, the patient gets daily blood draws, because no one gets sued over doing too much testing, although many patients in fact become anemic thanks to days and weeks of constant lab testing.
If the case becomes more complex and there are signs of complications — say, a heart attack or kidney injury — then sub-specialists are consulted, lab tests are ordered to cover everyone’s collective ass, and the cost begins to skyrocket.
As one of my colleagues said recently (a man with decades of experience and impeccable credentials), “If they gave me 10 patients to see a day, I would rarely if ever consult sub-specialists.” He was not joking.
Let us say that the patient eventually requires all the bells and whistles of modern medicine. They go to the ICU on a mechanical ventilator, with a central line through which infuse a dozen different medicines, and they even go into renal failure and require dialysis. This is what doctors call “a train wreck.” They see every sub-specialist and get every test. Many people make it through this scenario. Let us assume that everyone who survives pneumonia has the same life expectancy after surviving, whether they walked away from the office with a $10 antibiotic or suffered through a $100,000 hospitalization (which would be a bargain-basement price for a complicated pneumonia that required ICU-hospitalization). Let us say that we expect each of them to survive for 10 years after their diagnosis.
You can see that the $10 we spent “buying” ten years of life for the uncomplicated pneumonia that did not require hospitalization pales in comparison to the $100,000 we spent saving the poor patient who went through the ICU. This is how the cost of care breaks linear relationships. The ability of the system to pay for this depends upon having enough healthy people who end up paying $20 for their antibiotic, to have $100,000 that can be spend on the hospitalization. So the affordability of healthcare fundamentally depends upon the ratio of those who can make it on a $10 antibiotic and “train wrecks” who will soak up $100,000. In reality, we know that after a certain point, there is no meaningful hope for the patient. Their life becomes one of suffering and torment, without much if any meaning. As the cost goes up, the likelihood of this does as well. Likewise, many patients end up with multiple expensive hospitalizations over the last few years of their life. Much of the expense of these hospitalizations ends up adding nothing to their life expectancy or their quality of life. They are the epitomy of “waste.” They exist because doctors are so strongly incentivized to over-test and over-treat, so that no one has an excuse to sue the doctor or the hospital over a poor outcome. Doctors today do not have the time to explain to patients and their families when it is time to call it quits. Frequently, the incentives are aligned so that doctors and hospitals make money prolonging life, after all hope of a cure has gone.
Fourth and fifth line chemotherapy is a great example of this. By definition, fourth or fifth line chemotherapy has no chance of curing the patient, and yet can fetch hundreds of thousands of dollars over just a few months. Everyone feels good about “fighting the cancer,” even if it leaves society with so little money that no one can afford college, a new home, or a new car. As you increase the amount of money you spend on care, you do not necessarily improve the quality of the patient’s life or their life expectancy. Many people do not want to suffer if there is no chance of a cure. Why force them to? That is effectively what current insurance schemes do. They cover “everything” without explaining to you just what that means.
Ultimately, how much care you desire depends upon your appetite for risk, your beliefs about what “good medicine” is, and what quality of life you are willing to accept. Say that you do not want to take any chances of ending up “a vegetable” who is dependent upon machines. Your healthcare costs will probably be quite low, meaning that your insurer should offer you a lower premium. Instead, they sell you packages that do not explain the nuances of risk, reward, and non-linearity, and so you end up stuck with a premium you cannot afford that will pay for things you do not want. If you are happy to be a vegetable who needs to have their chin wiped, their lungs ventilated, and their diapers changed by other human beings, then you should pay for it.
The solution to this problem is to allow people to work with their doctors to define what kind of care they want, how much of it they want, and then to allow them to bargain with insurers to obtain the cheapest price for that care possible.
4. “Drugs make us healthy.”
This could not be further from the truth. Drugs do one thing and one thing only — they break normal human physiology. Using drugs to treat disease is like using the emergency break of your car to stop an accident. If you are using the emergency break, you have already made a series of mistakes that have led to the accident. It is a sub-optimal solution. Sometimes, it is vital. Yet the longer you rely on drugs to break an already broken system, the shorter your life expectancy and the more care you will end up requiring.
Because drugs do not create health. Life is the engine that runs itself and fixes itself. This is why gene-therapy has been fraught with problems and remains a pipe-dream. Sometimes, people need drugs for long periods of time. Yet in all of these cases, you will notice that no one studies how little of the drug they actually need. Drug companies pay for studies and only publish studies that establish the need for and the value of their drugs. The vast majority of drugs treat conditions that can be entirely prevented or cured by simple diet and lifestyle changes. This is not even to mention the fact that the drug companies have made a farce of our regulatory process by creating a dizzying array of ways to keep their drugs expensive. We will never know how few drugs we actually need until someone has an economic incentive to study it.
Why don’t doctors stop drugs that patients do not need?
Because we need time to talk to patients if we are going to determine the risks and benefits of stopping drugs. No one sues you for continuing drugs, but they do sue you if you stop a drug that the patient still needs. I routinely stop home medications in my hospitalized patients only to find out that they absolutely do not need them, or, worse, that they are actually contributing to the problem. A great example would be falls in the elderly. Most people over sixty seem to be on a few different drugs to lower their blood pressure. The problem is that this ends up increasing the rate at which they pass out and fall, which leads to a lot of broken bones that require hospitalization and an operation for repair. I consistently find that these patients do not need their blood pressure medications. Aggressive control of blood pressure is often doing more harm than good.
5. “Surgery and invasive procedures are great!”
Your original hip isn’t working anymore? Get a new one! Your stomach holds too much food? Make it smaller! Your breasts aren’t big enough? Make them bigger! Your heart isn’t pumping quite right? Replace it!
I am no skeptic of the values of surgery — I see the benefits every single day. There are plenty of surgical procedures I would readily sign up for if I needed them. “If” being the key word there. Yet what we find with surgery and invasive procedures is that they come with hidden downsides that end up playing out over years or decades after we have already committed to them.
Did you know that you have a much higher risk of suicide if you get breast implants or bariatric surgery?
Not all that glitters is gold. “It seemed like a good idea at the time” describes many surgical procedures and interventions that have since been relegated to the graveyard of medical history, but not before the bodies were piled high enough and deep enough that no one could continue making excuses like, “it’ll work this time!” Yes, we all may run afoul of a nasty accident or we may have an occupational stress (like, say, tennis elbow) that may lead to a need for major surgical intervention. Ironically, the vast majority of a trauma surgeon’s time is spend taking care of frequent fliers or repeat offenders — the town drunks and rabble-rousers who just cannot keep their cars on the road and cannot keep themselves out of bar fights. Accidents happen, but most of the surgeries we do every year are entirely preventable.
The solution to this problem is to explain to people how what they do increases the likelihood of needing a surgery (running shoes should carry a surgeon general’s warning that they may lead to knee and hip replacements! Modern orthopedic surgery owes a collosal debt to the fitness industry) and to sell them a plan for how to pay for it, before it happens, and likewise to minimize the co-morbidities that will increase its likelihood (in other words, they should be able to tell you how much your risk of requiring a knee replacement increases for every pound of fat you pack on).
I hear these themes and variations on them used day in and day out to justify an number of schemes proposed to “fix” the US healthcare system. The US healthcare system is a complex system, which makes me skeptical of any top-down, centralized solutions to its problems. These have, historically, seemed to create as many problems as they have solved. The facts are that American healthcare has become an overbuilt monstrosity that isn’t deliverying to anyone what they want, whether it is under or over delivering. Once you see the above five fallacies for what they are, you can open your mind to the wonderful possibilities that we have for providing care for everyone, regardless of their ability to pay or how much care they desire.
These five falsehoods have created the modern healthcare crisis, but they have had plenty of help. Part two of this series will focus on how governments have been bribed by corporations into creating the perfect storm for our modern disease epidemics. The modern healthcare crisis is a two-headed problem that deserves at least two blog posts before we address possible solutions.