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Guest Post on Controlling Medical Costs

My brother, Lee Evslin M.D., who is a pediatrician and who runs the Makai Ola Clinic on Kauai, wrote the email below in response to my post Medicare – The Promise That Can't Be Kept. He has a very different (and more qualified) point of views; so I asked if I could run this as a guest post. Of course, I'm reserving the last word for myself in a post to come.

Hi Tom,

Your blog on Medicare was interesting. Your line of reasoning though is an example of a concept you have spoken about since we were young.  You are looking at the problem through the same thinking that got us into trouble in the first place.  The problem will never be solved without a new way of dealing with ill health.  

Michael Pollan wrote an op ed article for the NY Times which does a fair job of describing one part of the problem. His article was about the "elephant in the room".

He is basically talking about the health care costs stemming directly from the food we eat. Health care in America is costing us 2.3 trillion dollars per year. This is twice what is paid on a per capita basis in Europe. For this staggering cost, we rank 37th among developed nations in health care outcomes. It is estimated that 75% of our health care costs are spent on chronic diseases.

Obesity is a major factor in causing cardiovascular disease and diabetes. Cancers of the prostate, colon and breast are also thought to at least partially be caused by our western diet. Obesity in America has almost tripled since 1987. Obesity (defined as a BMI over 30) has gone from about 13% of the population in 1987 to about 33% of the population in 2004 and an amazing 66% of the population are considered overweight. It is said that we are the fattest nation in the history of the world.

Bottom line is America's processed food industry is taking American government subsidies and producing food which has led to an epidemic of obesity and ill health. Chronic diseases are costing all of us 1.7 trillion dollars (75% of 2.3 trillion dollars).

Fix our food and we would go a long way to fix America's health care cost problem. Michael Pollan's point though is that this is not so easy. The processed food industry has enormous influence and even in Obama's crusade on health he was not able to take on the food industry at the same time as he went after the insurance companies.

The literature has numerous studies showing that everywhere the standard American diet goes, chronic diseases follow right behind. I have listed a few of the more commonly mentioned studies below:

In the 70s, a large study followed Japanese men and their diets as they moved from Japan to Hawaii and then to the west coast of the US. Heart disease rose with exact proportion to their adoption of the western diets.

BBC News reported recently that the British Journal of Psychiatry published data on 3500 government employees who were followed over five years. They found that those eating a diet "high in processed foods had a 58% higher risk of depression than those who ate very few processed foods."

They then subdivided those who were in the whole food group into two subgroups; those who ate mostly whole foods and  those who ate somewhat less whole foods.  Those eating the higher quantity of whole foods had 26% less depression than those who just ate somewhat less.

The Heart.Org reported recently on a study published in Lancet.  They presented the extended follow-up of a study known as The Diabetes Prevention Program (DPP).  The first results, published in 2002, showed that lifestyle change (diet, exercise, and weight loss) resulted in 58% less new cases of diabetes than in the placebo group. They also compared these results to patients put on metformin (a diabetes drug). The metformin group had only 31% fewer new cases of diabetes. In other words, life-style changes prevented diabetes almost twice as well as drug therapy and lifestyle changes also decreased the number of new-onset diabetics by almost 60% over those who did not change lifestyles.

The Archives of Internal Medicine reported on a German study which followed 23,153 adults ranging in age from 35-65 years. They were followed for 7.8 years. The four factors studied were:

Adherence to a diet which was high in fruits, vegetables and whole grain foods and low in meat consumption;

Never smoking;

Having a body mass index (BMI) less than 30 (A BMI of 30 and above is considered obese.);

Exercising 3.5 hours per week;

Those that followed all four positive lifestyles showed a dramatic decrease (78%) in the risk of developing one of four common chronic diseases. There was a 93% decrease in diabetes, an 81% decrease in heart attacks, a 50% decrease in strokes, and a 36% decrease in cancer. Can you imagine the profit and publicity from a drug that had the same preventative effects?

The diet described above, which is high in fruits, vegetables, and whole grain foods, and low in meat consumption, is the basis of the increasingly popular Mediterranean Diet. The Mediterranean Diet also includes nuts, legumes, olive oil, wine, and fermented dairy products such as yogurt and natural cheeses.

The Mediterranean Diet has proven beneficial in numerous studies. One Italian study showed that 50 of 90 people (56%) were cured of metabolic syndrome (high blood pressure, high blood sugar, and obesity) after 10 years on a Mediterranean Diet as opposed to only 12 of 90 people (13%) improving on a low fat diet. Other studies have shown the Mediterranean Diet to be associated with a decrease in abdominal fat, decreased risk of dementia in the elderly, decreased allergies in children and improvement in the health of the cells lining the blood vessels.

These studies speak well for themselves. The evidence is truly pouring in from around the world.  Processed foods and diets high in sugar and unhealthy fats are making us fat, plagued with chronic diseases and increasingly depressed. 

Bottom line:  The cost of medical care could be decreased dramatically if we stopped poisoning ourselves with our food and unfortunately "poison" is probably not too strong a word.

The food is one part.  The second part is quite complex but involves the industry of pharmaceutical and medical interventions that has grown around the fact that we have become unhealthy as a population by the food and lifestyles we have chosen or adopted.  First, we make ourselves really unhealthy and then we spend trillions treating the symptoms and not treating the underlying causes. There is an old analogy concerning treating a sink with a clogged drain by mopping the floor rather than by unclogging the drain or turning off the tap.  We will never solve the fact that our medical care will bankrupt the country until we fix our food and pay our medical care industry more money for reversing disease than we pay for applying really expensive bandaids.

Your Brother Bill

Medicare – The Promise That Can’t Be Kept

The promise was simple: once you reach 65, Medicare will assure that your medical costs don't become a catastrophic burden to you or children who might feel obliged to care for you. Since President Lyndon Johnson signed the Medicare bill in 1965 and gave exPresident Harry Truman the first enrollment card, the definition of "catastrophic burden" has been lowered many times by both Republicans and Democrats, the cost of medical care has skyrocketed as has the number of possible (usually expensive) medical interventions, and life expectancy has increased. The promise cannot be kept!

Geezers like me who recently reached 65 on the average had put in only on dollar for each three dollars of benefits we'll receive. That's a huge UNEARNED benefit. We didn't know that we'd be ripping off those still working but we are. The cap has been taken off earnings subject to Medicare tax; rich people pay a higher tax on their earnings than poor people. Premiums for recipients have been raised for those who are still classified as high earners. Payments to providers have been cut back forcing other users of health services to subsidize Medicare. But the funding gap keep growing inexorably as the number of workers supporting each retiree shrinks, we live longer and longer, and ever more ingenious (and expensive) medical procedures are invented. Raising taxes on the rich wouldn't solve the current problem let alone the future one; there's no one to pay for our care but us and our kids. Charging the kids more now means there's an even bigger gap when they retire. The promise cannot be kept!

The future of Medicare is a lousy campaign topic because there is no good answer. Politicians made us a promise they can't keep. We believed what we wanted to believe. And now there'll be a Medicare default plus an expensive Medicare bailout. There's no one to sue. We have to pay the piper both in terms of benefits we won't receive and money we'll have to pay.

Cutting benefits to current retirees is both unfair and absolutely necessary. We were promised our medical needs would be taken care of, so we didn't make any provision other than the Medicare tax we were paying. We didn't think we were getting something for nothing. We didn't have the chance to choose a different option. But we getting $3 of care for each $1 we paid. Our premiums can – and should – go up on a means-tested basis. Which procedures are covered should be more tightly restricted, although we should retain the option of paying for them ourselves if we or our heirs can. I'd like the option of opting out, self-insuring for routine stuff, and buying only catastrophic insurance. It may be, however, that giving me that option and forgoing my already higher premiums would make the problem even worse. Perhaps the more well-to-do ought to be able to buy themselves part way out. There is no answer that's fair to those already in the system or close to retirement. It's just a question of limiting the damage. The promise cannot be kept!

We can't keep the promise to today's workers that they can have medical care from 65 to the grave at almost no expense to them or their heirs. We need to tell them the truth and let them make some choices now. Private insurance can provide plans for retirement coverage – but it is hard to convince a twenty-something to forgo current expenditures to pay for those impossible to imagine days as a geezer. But young people do pay into retirement funds; they do (sometimes) save for their own kids' college. Under compulsion, they're paying for Medicare now; but we're spending every penny they're paying. I don't think it's a terrible injustice for those who have money but failed to buy insurance to have to sell their (or their heirs) assets in order to pay for the medical care they want. We spend our retirement funds on our other priorities. I would've sold my house to pay for my stent if I'd had to – or chosen a lifestyle that let me work around a damaged artery. What's essential is to present these options to current workers today so that they can still make a choice. We cannot make them promises that can't be kept!

I'm sure you've noticed that I haven't talked about what should happen to those who couldn't afford insurance and can't afford medical care. That's a different, although still critical, problem. The Medicare problem is a promise made to us who had alternatives, a promise there is no one to pay for except us, which turns out to be a promise that can't be kept. The sooner we recognize the default, the less the pain of curing it.

Related posts:

Rep. Ryan's Budget: Change You Can Believe In

Medicare's a Fraud – And I'm the Beneficiary

We Can't Have All the Medical Care We Want

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