Can The Government Actually Improve Wellness?
The debate rages on about healthcare reform and insurance, but what can politicians, through legislation, actually do for wellness? WellBe Founder Adrienne Nolan-Smith had a phone conversation with Bob Moffit, Ph.D., of The Heritage Foundation, a conservative think tank. Moffit is a senior fellow at their Center for Health Policy Studies and specializes in healthcare programs. Nolan-Smith was curious to see whether any of the Republican-run White House and Congress’ plans would help (or hurt) the wellness movement. In alignment with The Heritage Foundation’s perspective, Moffit did not believe a single-payer healthcare system was the answer for wellness.
Adrienne Nolan-Smith: I’m going to throw out some numbers related to chronic disease:
The CDC estimates 86 percent of American healthcare costs are related chronic disease.
In 2012, 50 percent of Americans had at least one chronic disease, 25 percent had two.
In 2010, 70 percent of deaths were related to chronic disease; heart disease and cancer accounted for half of that.
In 2016, roughly 70 percent of adults were considered to be overweight or obese, up from 45 percent in 1960; 36 percent of adults are considered to be obese.
Have you considered reducing the burden of chronic disease as the way to fix the healthcare system instead of focusing purely on the insurance cost once it has already been incurred?
Bob Moffit: That’s exactly right, all those numbers are accurate, 117 million Americans have at least one chronic disease. It is the major driver of healthcare costs, no question. It seems to me that as a matter of policy the only way to actually [reduce the chronic disease burden] is to use the leverage of financing, which means we have to come back to insurance.
There’s no question that ultimately healthcare is based on a lot of factors and variables, which are completely beyond the control of any kind of government official or policy provision. One time a doctor said to me, “Moffit, people dig their graves with their knives and forks. People who are taking pills, are taking pills because they will not do what we tell them. Which is to change their diet and go exercise.”
I remember an endocrinologist who was on the board of directors of the American College of Endocrinology said, “There is no pill that we can prescribe to a patient that will replace 45 minutes of intensive cardiovascular exercise, 3 or 4 times a week. There is nothing the medical profession can do that could replace that, in terms of oxygenating your blood and improving your health, and your heart in particular.”
The problem is, we don’t do it. We eat too much, we drink too much, we don’t exercise, we’re sedentary. And in fact, part of the healthcare problem is a function of our economy, in the sense that we live in a world where [most] people earn their living by sitting.
Do you think our car-centric culture and the quality of our food that might be contributing to the recent drastic rise in chronic disease?
There’s no question about it. This is a multi-factor problem. In Anne Arundel County where I live in Maryland, they just put in both a walking path and a bicycle path, and people actually use it. Is that a good thing? Yes, it is. Was it a good use of taxpayer money? I think so. It was a local decision.
With regard to actually effecting change, it has to be done through the healthcare financing system. I have a couple of suggestions. One is that we eliminate, or radically amend, the anti-discrimination laws for insurance, to provide premium discounts in health insurance for people who enroll voluntarily in preventive health and wellness programs. In Switzerland, 80 percent of funding for healthcare is private—it’s all basically competing private health plans. The health plans there recognize that if these people keep themselves healthy and don’t file claims, the cost will go down, the market will be stabilized and people will be happier and healthier.
Insurance companies don’t want to pay clients’ claims. They want to take that money and invest it in the market and they have the perfect right to do so. So how does Switzerland handle this? If you sign up for five years and enroll in a wellness program through your doctor, you get rebate money. It’s in their financial interest to keep you healthy and it’s in your financial interest to invest in your own health by getting a rebate which is going to reflect your commitment to the right things.
Employers could do the same thing here, frankly, but once again you have to change the laws to allow employers to do it. We have all kinds of employer wellness programs, most of them are unsuccessful. One way to encourage this is for employers to provide premiums, discounts, or rebates for people who enroll in employer-sponsored wellness programs. Because it is also in the interest of employers to keep their employees healthy and it’s in the interest of the employees to be healthy. And how do you make that connection real, you make that connection real with a check.
It’s sounds like you support health savings accounts (HSAs)—is that the case? What do you think about the federal government dictating limits on what HSAs can be used for?
I’m against the limits on HSAs. I think we should create HSAs and separate them from insurance. We should create HSAs as standalone accounts, where people can use them for anything they want as long as it’s focused on health, which could mean buying insurance, making a direct payment to a physician or an exercise wellness program.
You believe the government should eliminate barriers to personal choice in healthcare. Based on a couple of major health challenges I went through, I am now a big consumer of Traditional Chinese Medicine (TCM) and regularly undergo acupuncture for my back pain and take herbs for immune support after my battle with chronic Lyme. Sometimes I can submit that kind of treatment to my HSA, but sometimes I can’t.
That to me is an unnecessary restriction on your freedom. There is clinical evidence that Chinese remedies do in fact work. I know acupuncture is covered by a lot of insurance. In some states, it’s even mandated, which I think is wrong. The only thing I’d mandate would be catastrophic coverage, so if you end up in hospital emergency room and it’s going to cost $50 or $100,000 to put you back together, we shouldn’t be hitting a taxpayer with that.
The USDA spends more than $25 billion a year on farm subsidies, most of which are for wheat, corn, soybeans, and rice from large factory farms. Meanwhile, vegetable and fruit farmers get less than 1 percent of that. Do you think the subsidies take away the incentive for farmers to produce fruits and vegetables in favor of artificially inexpensive food?
I don’t think there should be any farm subsidies anymore. I think that came out of the Great Depression— the 1930s are over, World War II solved the problem. The government should not be picking winners and losers, period. Very simple.
Since chronic disease disproportionately affects lower income people and the cost of Medicaid their healthcare falls on taxpayers, shouldn’t the food stamp program be focused on nutrient-rich foods in an effort to reduce the taxpayer burden? Currently foods with low or zero nutrients, like soda or processed food products, are allowed.
I’m partial to the idea, but I’m not an expert on the welfare system. I think one could make a very good argument that if we’re going to use public money, it has to be spent wisely. And that it is not a matter of personal freedom but rather a matter of receiving a subsidy from the government for a specific purpose, and the government can define that purpose as providing nutritious food to low-income people. Whether it’s a good idea or not, I’m not sure.
Medicare and Medicaid are seen as unfunded liabilities, meaning we don’t have the money set aside to pay for them. When I was working in conventional healthcare, one of my projects was focusing on state Delivery System Reform Incentive Payment (DSRIP) programs, which is basically Medicaid reform at the state level. A couple of different states are participating in it right now, and I have to agree that these programs are quite costly in their current form.
But I also noticed that the Centers for Medicare & Medicaid Services (CMS) was the only player in the healthcare system that was trying to push hospitals and doctors to practice value-based care (payments based on the health outcomes of patients), rather than fee-for-service (payments for each type of treatment they get) and get out of the fee-for-service system.
How would you suggest getting rid of fee-for-service if CMS isn’t around or isn’t flexing its muscles to do so?
I think the first thing to do is that the default when a person turns 65 is to get on a Medicare Advantage Plan. Right now, the default is Medicare fee-for-service, in which there is no relationship whatsoever between the value of a service and what you get. Whereas with Medicare Advantage, you get a lot of care, coordination, case-management and a very strong emphasis on preventive care. So why don’t we change the default, from Medicare fee-for-service to Medicare Advantage. The second thing to do is let Medicare Advantage and Medicare fee-for-service compete directly on a common playing field and provide good solid information on medical health.
The U.S. is the only country in the world besides New Zealand that allows direct-to-consumer advertising by pharmaceutical brands. We happen to also be the most medicated and chronic disease is the leading cause of death and disability. Do you think this should be allowed, do you think there’s a correlation, what is your stance on that?
I don’t think there’s anything wrong with direct-to-consumer pharmaceutical advertising, I think people have to make their own choices. Whether it’s pharmaceuticals, the use of alcohol, the use of cigarettes or anything else. I think people should exercise their personal freedom. I’m not in favor of giving the government censorship authority over that.
However, at the same time, I think that the public education campaign has got to improve and that the medical profession has got to step up and do its job which is to say, “Look, a lot of these drugs are not good for you, they have side effects that are bad and you ought to take that into consideration.” I think at the end of the day there’s a limit to what [government] can do, there’s a limit in protecting people from themselves. At the end of the day, you’re ultimately responsible for yourself.
In America, the general belief has been that whatever your doctor says, goes. I’ve been to several doctors who gave me terrible advice, and I had to do a lot of my own research and be very forceful and turn down their options. Culturally, I don’t think a lot of Americans feel like they can do that. How do you get people to feel empowered to take responsibility for themselves?
One way to do it is to encourage at least two or three opinions from specialists in the field anytime there is a major decision. The second thing to do is take advantage of information that is available in comparative medical performance in terms of the outcomes and results of physicians. We’re starting to do that with hospitals and that makes a lot of sense.
In my situation, I was comparing treatment for Lyme disease between completely different approaches, not physicians. The physicians only offered antibiotics while the TCM practitioner offered a diet- and immune-support-based approach. How are people supposed to find information comparing treatments and outcomes?
Well, I think we’re working on it. We have to work on both outcomes, data, and price transparency. I know that a lot of conventional medicine does not work in many cases and in those cases the better standard is things like eating certain nutrients. For example, one thing that we’ve learned is that the combination of fish oil and red yeast rice is a major contributor to a decline in LDL cholesterol, which is a big deal for heart disease. People should be talking about using [integrative] medicine. Another thing you can do is encourage people to get the blood tests that would tell them whether in fact they have low potassium, low magnesium, things like that.
Another problem is that doctors don’t have any experience with nutrition.
I think it’s something like less than 15 total hours are taught in four years of conventional medical school.
Yeah and that’s not enough, it’s not enough. I had lunch one time with this very famous urologist from Wisconsin and he was one of the best in the business and he said, “Let me ask you something: Let’s say you have a horse, the horse goes lame and you call the veterinarian. The veterinarian comes to the stable. What’s the first question that the veterinarian is going to ask you?” They ask, “What have you been feeding the horse?” That is the first question that every doctor should ask every patient: What are you eating?
This interview has been edited and condensed for clarity.