Friday, January 01, 2010

Health care reform: how much difference will lifestyle choices make?

The Washington Post carries a provocative op-ed by former AOL chairman Steve Case on page A15 of its New Years Day 2010 paper, “Health-care reform begins at home”, which online is titled (revealingly) “Health-care reform requires healthy living choices”. The link is here.

Case points out correctly that the debate is about how to pay for health care, not just how to deliver it, but then he moves to saying that we have a “sick care system” and not just a health care system. He then makes the arguments that we all have moral responsibilities to make healthful lifestyle choices, especially with regard to diet, exercise, and cigarette smoking, and probably drug and alcohol abuse. He doesn’t explicitly mention STD’s because that can lead to some very sensitive areas. And he’s right in that, if there is a moral debate over whether the young should pay higher premiums to care for the old or the healthy should pay more for the sick, there’s a deeper moral debate on how we live.

Of course, at an individual level, better lifestyle habits will usually or often reduce medical expenses. If we live more healthfully, we will need medical services less for many years. But we will also live longer. And living longer also means that eventually we still may use the services because we have more years in which to use them. There’s a double-edged sword here in medicine here. It’s true, we’re pretty good ad making sickness go away and in postponing disability. But in the long run, as people live much longer, there is still more extreme disability at the end of life. And medicine is very good now at extending life even with extreme disability. The need for end-of-life long term care is growing rapidly, perhaps explosively in mathematical numbers, because of demographics and because of the way medicine can be practiced now, and may soon outstrip the ability of institutions (assisted living centers and nursing homes) and for-hire home based providers to provide services without more family involvement . And there’s another point. Even among the young, many diseases, recently becoming treatable by medical advances, are genetic or congenital, or beyond the control of “life style choices.” At the same time, the ability to treat these diseases improves with technology. At the same time, families are smaller and more widespread. This makes treatment of some conditions, even in the young, more difficult if extended family members cannot sacrifice for them (even with organ donations for some newer technologies). Social conservatives make a lot of the decline of the family as a motivating force in society; and when it comes to medical care and long term care, they may have a point: the demand for care in these more demanding situations is increasing partly because medical technology can provide the care; but without the social commitment underneath, society and the health care system winds up having to make decisions about triage.

It’s good, however, to see a piece on health care by someone from “Silicon Valley East”. I remember how Case had to struggle with the "terms of service" issue in the 1990s when Internet service was newer, and had to develop a philosophy that voluntary compliance was the only way to make huge public infrastructures work well.

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