Sunday, March 25, 2012

Supreme Court Should Consider Issue of Far Greater Consequence

Tomorrow, the U.S. Supreme Court is set to hear arguments about the constitutionality of the Affordable Care Act (Act), which some refer to as “Obamacare.” The most contentious of the Act’s requirements is called the Individual Mandate that requires citizens to secure health insurance or pay a fine. The idea behind this mandate is that too many people do not have insurance, which is ultimately bad for society. Yet, there is more to Obamacare than just the Act.
While the Supreme Court’s decision will surely be deemed monumental, it may very well be misguided. Instead of deciding should everyone have insurance it could be ruling on something far more consequential—what role should individuals play in staying healthy and preventing disease? Instead of focusing on insurance, we should be focusing on what creates the need for it. Undoubtedly, both the greatest expense and greatest determinants in health care are prescribed by what we do and how we act. 
A fact that is widely ignored is that another facet of Obamacare actually addresses this issue by supporting many primary preventive measures that can profoundly impact the future of our health care system.  These measures offer the opportunity to debate a fundamentally more intrusive issue of far greater consequences. Can and should our government impose a mandate on its citizens to maintain good health by requiring adherence with preventive measures in order to access cost-effective health coverage? Or should our tax dollars continue to fund free, unlimited healthcare for people, such as smokers, who with gross negligence majorly contribute to their expensive, chronic poor health?
To help answer this question, we must first address the efficacy of primary prevention, which concentrates on the mitigation of health risk factors created by lifestyle. These factors include diet, physical activity, stress, sleep, smoking, and alcohol, to name a few. Many who challenge the cost versus benefits of prevention include diagnostic tests as part of the equation.  They argue that the incidence of false positive tests increase rather than decrease costs.
For the sake of discussion, I choose to ignore such tests because they typically diagnose rather than prevent disease; although, some basic blood tests, such as for cholesterol and sugar, can be helpful in identifying risk factors for heart disease and diabetes. However, primary prevention is mostly based on lifestyle modification through counseling and education.  The Centers for Disease Control state emphatically that the evidence for the power of prevention is now indisputable. Numerous well designed studies now support the assertion that lifestyle modification can and will improve health and decrease healthcare costs.
Some 2,500 years ago, Hippocrates wrote that “prevention is preferable to cure” and over 200 years ago, Benjamin Franklin wrote that “an ounce of prevention is worth a pound of cure.” I humbly put forth a new spin on this concept--"prevention is the best insurance.”  This is not meant to be a mutually exclusive concept. Obviously, insurance has a role to play.
Cars are a great example of this duality.  While the law mandates that every car be insured, it also regulates countless other aspects of safety measures such as seat belts, airbags, turn-signals, traffic rules, etc. To drive, one must have a license and to get a license, one must pass knowledge and skill tests.  Drivers with clean records are rewarded while other drivers pay penalties. We require car insurance because cars can cause much damage to human life and property; car accidents can be catastrophic. So why are we so regulated in reference to cars and not health? Are unhealthy lifestyles any less catastrophic to the person and society, which ultimately bears the cost for care for those over 65?
However, when it comes to health, the major legal debate seems to be about insurance and its related costs. Why is there limited discourse about preventing the types of problems for which most of the costs related to insurance are spent—chronic diseases? Interestingly enough, when the Obama administration drafted related legislation with the help of Congress, it recognized the need for both and added Medicare's first coverage of primary preventive services meant to identify health risk factors and address them before they become full blown diseases.  
Surely, insurance offers peace of mind when you get sick. Used properly, it can stop small problems from developing into more severe, if not life threatening issues. However, insurance does not in and of itself prevent health problems. Some may even argue that it does just the opposite by creating a licensing effect that allows us to live our lives without fear of health consequences because we expect our insurance to pay for the needed medical interventions when we become sick. This over-reliance on treatment instead of prevention is probably the root cause for our spiraling up health care costs that now consume 17% of our gross national product.
Obamacare also facilitates the Centers for Medicare & Medicaid Services (CMS) to institute a number of initiatives related to health care innovation intended to improve care, increase access, and decrease costs. At the same time that the Supreme Court will be hearing arguments next week, CMS is set to announce grants totaling up to $1 billion to funding innovations meant to cost-effectively improve health and health care. Innovations may be game changers. Government should incentivize good health practices, just like car insurance companies reward good driving records, lower premiums for students with good academic records, and for those who complete driver’s education classes, by implementing new incentive-driven lifestyle interventions that could pay huge dividends by decreasing health costs while improving health.
We as a society have already accepted both the need for insurance and the value of preventive measures related to cars. Doesn't it seem logical to do the same in relation to health care? With 78 million baby boomers set to swell Medicare's already substantial ranks, we can hardly afford the delay. Obamacare may not be perfect, but I think it is a step in the right direction.
Although, I lean Republican (compassionate conservative) and will most likely support the next Republican nominee because of other issues I have with the Obama Presidency, I am first a doctor looking out for the best interests of his patients.  Today, Obamacare best meets that priority.

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