Healthcare Diversions, Part 1: The Elephant in the Room

I have tried to stay clear of the current healthcare debate because all sides appear to be so far from any sensible policy that I remain indifferent to the outcome. However a recent three-hour layover in a major airport in the “new South” brought into sharp focus—at least for me—the elephant in the room that no one wants to discuss.

I won’t belabor the obvious point that Americans are, to put it delicately, a bit on the hefty side. But what really struck me is that many have evolved to the point that they are barely bipedal. As passengers attempted to perambulate their way from one gate to the next, it appeared that most had forgotten how to walk. I saw the most ungainly gaits—peregrination with great effort but little forward progress, the zigzag, the toe-heel-toe, the Quasimodo, the sideways roll, the zombie, the stop-start-stop again, all whilst occasionally careening off walls and other passengers. Of course, in some cases the attire dictated the method. A few of the boys had their pants waist bands down around their knees, forcing a duck-like waddle, made even more difficult by the need to use one hand to hold onto the belt lest gravity complete its work and bring the pants down to the ankles. A lot of the girls wore PJs and flip-flops, making it impossible to do much more than shuffle along. Some forty-somethings had eight inch stilettos in which only flamingos could parade about with grace. Still, the vast majority of passengers wore shoes marketed as sporting equipment, designed presumably for activities involving two legs and an upright posture rather than for those of the aquatic or slithering or knuckle-dragging variety.

And here is an interesting factoid: the average American walks just the length of three football fields daily. (Sierra Magazine, Jan/Feb 2007, p. 25) It shows. Since that is the average, it is no doubt boosted by the still considerable number of aging yuppies who manage 3k runs before breakfast, as well as by children the soccer moms idolized by Sarah Palin drive to practice. I presume that most of the airport patrons typically manage little more than a few schlepps from couch to fridge each day, taking a momentary break from their average 1600 hours in front of the TV each year. (Uncle John’s Bathroom Reader, 2006 p. 115)

Like many other airlines, ours had provided a welcoming speech as the plane pulled up to the gate, helpfully reminding passengers that the most dangerous part of their journey would soon begin. I had always thought that they were alluding to the fact that we would shortly be behind the wheel of our autos, taking our lives into our own unprofessional hands as we attempted to pilot 2 tons of steel on a 65 mph freeway through an obstacle course of text-messaging drivers (which studies show are twice as impaired as a drunk driver). Actually, they were referring to our more immediate mission—to walk without major mishap to the baggage claim area before returning to the relative safety of a seated or prone position in a vehicle, like the humans in the Wall-E movie. A few centuries ago, our ancestors here in America were able to run down buffalo, or even mastodons, and kill them with spears. Today, most Americans can, with some effort, spear a French fry—providing it is not moving too quickly and that they are seated to steady the aim.

Don’t get me wrong. I am not one of the contrarians who reject the argument that lack of access to healthcare by the uninsured contributes to the US’s relatively poor ranking in terms of health outcome. Surely that explains some of our problem. But too little exercise, too much smoking, too much food, and especially too much bad food have got to be a huge factor. As Michael Pollan argues (In Defense of Food, 2008), unless we address the problem with American Food, Inc., we will not significantly improve our health no matter what we do with health care. According to Pollan, the cost to society of the American addiction to “fast food” (which is neither all that fast nor is it food) is already $250 billion per year in diet-related health care costs. One-third of Americans born in 2000 will develop diabetes in her lifetime; on average, diabetes subtracts 12 years from life expectancy, and raises annual medical costs from $2500 for a person without diabetes to $13,000. While it is true that life expectancy today is higher than it was in 1900, almost all of this is due to reduction of death rates of infants and young children—mostly not due to the high tech healthcare that we celebrate as the contribution of our innovative, profit seeking system, but rather to lower tech inoculations, sewage treatment, mosquito abatement, and cleaner water. The life expectancy of a 65 year old in 1900 was only about 6 years less than it is for a 65 year old today—and rates of chronic diseases like cancer and type 2 diabetes are much higher. (Pollan, p. 93)

Smoking causes 400,000 deaths yearly. Simply banning smoking from public places throughout our country could reduce deaths by 156,000 annually. (NPR 22 Sept) We incarcerate a far higher percentage of our population than any developed society on earth—and health care costs in prisons are exploding for the obvious reason that prisons are not healthy environments. Our relatively high poverty rates, and high percentage of the population left outside the labor market (especially young adult males without a high school degree) all contribute to very poor health outcomes. In a very important sense that I will explore thoroughly in the next blog, more health insurance coverage would no more resolve our health care problems than would provision of car insurance to chronic drunk drivers solve our DUI problem.

So, before ramping up health care insurance, how about an education program to teach people the mechanics of walking. It is not as simple as it sounds. I speak from experience because some years ago I tore a calf muscle and after a long and painful healing process, I developed a gait that was all kinds of ugly. A physical therapist helped me to redevelop a human stride. While we are at it, we can reintroduce Americans to food. I don’t mean the corporate offal that Pollan calls “food-like substances”—products derived from plants and animals, but generated by breaking the original foods into their most basic molecules and then reconstituting them in a manner that can be more profitably marketed. What I mean is real food, produced by farmers and consumed after as little processing as possible. Preferably it will be local, cooked at home, eaten at a table, and will consist mostly of vegetables, grains, and fruits. And let us provide decent jobs to anyone ready to work, as an alternative to locking them up in prison. Ban smoking from all public places and regulate tobacco like the highly addictive and dangerous drug that it is. Together these policies will do far more to improve American health and to reduce health care costs than anything that “reformers” are proposing.

To conclude this part of the analysis: the benefits of extending health insurance coverage are almost certainly overstated and are not likely to make a major dent in our two comparative gaps: we spend far more than any other nation but do not obtain better outcomes and in important areas actually get worse results. Nations that adopt diets closer to ours begin to suffer similar afflictions: obesity, diabetes, heart disease, hypertension, diverticulitis, malformed dental arches and tooth decay, varicose veins, ulcers, hemorrhoids, and cancer. (Pollan p. 91) Even universal health insurance is not going to lower the costs of such chronic afflictions that are largely due to the fact that we eat too much of the wrong kinds of food and get too little exercise. It makes more sense to attack the problem directly by increasing exercise, reducing caloric intake, and minimizing consumption of corporate food-like substances that make us sick, than to provide insurance so that those who suffer the consequences of our lifestyle can afford costly care.

Let me be as clear as possible: it is neither rational nor humane to deny health care to any US resident. Further, I accept the arguments contending that early treatment through primary care is far more cost effective than waiting for emergency care—and it is obviously more humane. However in the next blog I will explain why I believe that extending health insurance is the wrong way to go if the goal is to extend health care coverage.