True population health change will not occur until people are incentivized to take responsibility for their own health.
“Will I have to tell someone we can’t treat a loved one because we’re out of ventilators, oxygen, tubes, masks, hospitals, staff? Will we then impose an age limit, as some hospitals…are considering, or will some notion of ‘deservingness’ come into play?”
“For years, health care workers have been raising the alarm that the [system] is in crisis — calling on the government for better funding for our hospitals and better working conditions for ourselves.”
While this may sound like the voice of a stressed, frontline healthcare worker in the US, as they deal with a broken healthcare system in the fight against COVID-19, in actuality, these are quotes directly from the New York Times Op-Ed, I’m a Doctor in Britain. We’re Heading Into the Abyss. Despite the very public struggles of government-sponsored healthcare systems, like the National Health Service in the UK, to respond to the COVID-19 pandemic, the situation has revived emphatic calls for a move to a national healthcare system here in the United States. According to an article in The Guardian, America's extreme neoliberal healthcare system is putting the country at risk; they claim “single-payer healthcare can’t prevent a novel virus like COVID-19 but it could help us plan, coordinate and save lives.”
If countries similar to the US also proved ill-prepared for the COVID-19 pandemic, experiencing serious shortages in staff and supplies as a result of a surge in demand, why is the current pandemic a good argument for moving to a national healthcare system? The ability of a healthcare system to respond adequately during any pandemic will always be directly related to the severity of the illness, which determines demand for healthcare services. On October 6th, 2020, the Centers for Disease Control and Prevention revised their guidance on people who are at increased risk of a severe illness from COVID-19 to include adults who are obese, overweight, and those who smoke or have a history of smoking. Also included on the list of risk factors are chronic diseases, such as heart disease and type II diabetes.
Obesity makes it more difficult to breathe, requires scarce specialized equipment and manpower, and uses higher quantities of drugs and other transient medical goods. Diabetes makes it much more difficult and labor intensive to manage a patient on a ventilator. Their lack of control over their blood concentrations and sensitivity to medication can lead to difficult to treat medical conditions like acidosis. For heart disease patients, COVID-19 can attack and further weaken the heart muscle, lead to blood clots, and causes the heart to work faster and harder as the respiratory system is damaged.
An argument in favor of a national healthcare system in response to COVID-19 might make sense if countries with such systems performed better for obesity and these chronic conditions, and they do, but only marginally so. Obesity rates for adults 18-years and older in the US is a whopping 37% but Australia, Canada, and the UK closely follow at 30%, 31%, and 30%, respectively. For a point of comparison, Japan, which has fared remarkably well during the pandemic, despite criticism over the Japanese government’s handling of the outbreak, has an obesity rate of just 4%. There is a similar story for type II diabetes: 9.1% for the US, and 7.3%, 7.2%, and 7.7% for the aforementioned anglosphere countries, and cardiovascular diseases: 30% for the US, and 28%, 25%, and 25% for the others.
Obesity, overweight, and chronic conditions, such as cardiovascular disease and type II diabetes, are largely the result of individual health behaviors, like food choices and level of physical activity, and not genetics. But what incentive does someone have to adopt healthy behaviors if the cost of any resulting healthcare they might need is covered by a third-party payer, government or private? Perhaps this is why, according to the Milken Institute, treatment for chronic health conditions totaled $1.1 trillion in the US in 2016, equivalent to nearly 6% of GDP. Similarly, 70% of healthcare spending in the UK is spent on treating long-term conditions. In all four countries discussed, the US, Australia, Canada, and the UK, and globally, rates of chronic disease are increasing at an alarming rate. Across the world, health systems focused on “sick care” are unprepared and unequipped to promote healthy lifestyles, which has resulted in high levels of the discussed COVID-19 cofactors throughout the world.
Despite the obvious role of the individual in determining their health status, healthcare reform efforts in the US have primarily focused on changing physician and provider reimbursements to improve their incentives for providing the “right” care. While this is a step in the right direction, true population health change, and we can now add to this pandemic resilience, will not occur until people are incentivized to take responsibility for their own health and adopt healthy behaviors. Moving to a national healthcare system would only serve to weaken these incentives, as everyone becomes eligible for care paid for by the collective.
However, healthcare is not immune to the issue of scarcity. As populations get sicker, national healthcare systems will have to develop new and creative ways to ration healthcare services and control demand; the scope of healthcare will have to broaden into health behaviors, and a government monopoly on healthcare will thus necessitate its involvement in the everyday lifestyle choices of its citizens. What form will that take? It might start out small, such as a tax on sugary beverages, which have been enacted in some US cities, and may advance to banning the sale of junk food, which we have seen occur recently in other countries. These restrictions could feasibly infiltrate healthcare services more directly, for example, BMI ceilings for those needing bypass surgery. While this may seem like a dark, dystopian future, these mechanisms are already put in place for really scarce resources. Consider organ transplants where the “deservingness” of the patient is always a factor in deciding which life to save.
The very real fears of the doctor expressed at the start of this piece, being put in a position of deciding “who gets care” as a result of COVID-19, could become the “new normal” under national healthcare systems that create collective accountability for the outcomes of individual actions. When health status today is so dependent upon individual choices in lifestyle, such a system promises nothing more than moral and financial bankruptcy. The US healthcare system is definitely flawed, but national healthcare systems are not the “silver bullet” they have been made out to be for curing what truly ails us. Perhaps, as we consider further healthcare reform in this election year, the legacy of COVID-19 should be to usher in the age of personal responsibility in healthcare.
Danielle J. Durant, PhD, MBA, MS, is Assistant Professor of Healthcare Management at Widener University and Austin Klein is a MD/MBA-HCM student at Sidney Kimmel Medical College & Widener University.