Being Healthy Is Not Just the Absence of Disease

January 26, 2011
Jeff Kaplan, MD

The health and economic costs of poor lifestyle choices, poor health care planning, and misaligned incentives for care are the themes this week.

In last week's post I discussed the slippery slope of high-deductible insurance that may create turbulent access problems that, downstream, become health hazards. In that post, a colleague commented about personal responsibility, disparaging the idea of first-dollar coverage by saying, “I believe that insurance should be for spreading the major costs of illness or accidents, not for the maintenance costs that everyone has.”

At what point does having large out-of-pocket expenditures hinder good, appropriate, and timely care? What is the role of health insurance when it comes to health maintenance and prevention? To what degree should we insulate people from the true cost of their care? Who pays for non-compliance when it comes to taking one's meds? Not getting screened? Making poor lifestyle choices?

Richard Cohen's salient commentary from "America's Declining Health" is that on a comparative scale, worldwide, we spend more on health care and we aren't healthier for it. Also, the economic constraints of our time wreak havoc, consequently leaving us poor at arresting "avoidable mortality." Poor health planning can only come at a price, both in terms of inefficiency and pain -- personal and pocketbook.

The political deconstructionists -- the ones who won the Congress; the ones who want to do away with the meager health care reform we scraped together through compromise and deals; the naïve optimists (like Pangloss), they are in for a rude awakening. We cannot treat health care as a medical business, a profit center; that is, the business of medicine is health care -- not profiting at the expense of a patient.

We cannot charge more for obesity, alcoholism, smoking, or xenophobia. We cannot make people exercise, eat right, or think right. But, neither can we be irresponsible in our health care dealings about (or avoidance of) the subject of lifestyle management.

If you look at "Association of Features of Primary Health Care with Coronary Heart Disease Mortality," you will find that, in England (and I assume almost everywhere), variation in CHD mortality is principally explained by population characteristics. Clearly, we've got work to do on our rampant adverse lifestyle choices. (Let's see who can park closest to the gym?)

For the stalwart promoters of health care, there's still hope -- greater detection of hypertension is associated with lower CHD mortality.