The Top Five Controversies in Health Care Today

The notion of comprehensive health care reform is not controversial anymore. Indeed, a December 2008 Washington Post/ABC News poll found that 77% of Americans, cutting across the ideological spectrum, felt that President Obama should tackle a major overhaul of the health care system, with a majority saying he should do so immediately after entering office.

But aside from a notion that our broken system needs fundamental change, there are significant differences of opinion as to when and how politics or policy should intervene.

1. Tackling Obesity

When we’re obese or overweight, we’re at increased risk for hypertension, type 2 diabetes, coronary disease, stroke, cartilage degeneration, respiratory problems and a host of other medical ailments, including some types of cancer.  This explains both why the Center for Disease Control collects standardized data on obesity from state departments of health each year, and why those stats should make us nervous.  In 1990, no state had a prevalence of obesity greater than or equal to 15% of the population.  By 2007, thirty states had a prevalence greater than or equal to 25%, and three of those states had a prevalence greater than or equal to 30%.

We, as a nation, are gaining too much weight.

On the one hand, it should be no surprise that behavior and environment are major factors for this.  In poorer areas and the inner city, fast food chains are ubiquitous and access to fresh vegetables is poor.  A more sedentary lifestyle for children at home, at school and in child care, combined with the allure of sugary snack marketing has caused childhood obesity to more than double in the past 20 years.

But on the other, many Americans are overweight due to genetics, metabolism or socioeconomic conditions.  How can government intervene with those who could easily combat the factors that cause them to be overweight without stigmatizing those who could not?   How will the libertarian instincts of Americans respond to any attempt at regulation or taxation of hamburgers, potato chips and beer – even if it’s for their own good?

2. Compensation for Primary Care Physicians vs. Specialists

There’s a reason why increased investment in primary care and prevention is touted in any serious health care reform plan. But there’s also a primary care physician shortage already in this country, to the tune of 45,000 or so.  If we were to enact universal coverage, that shortage would quickly turn into a crisis.  Why aren’t doctors going into primary care as much as other specialties?  There’s one factor we can’t ignore anymore:  compare a pediatrician’s average salary ($175,000) to a cardiovascular surgeon’s ($558,719).

Certainly, some specialties often require far more training, worthy of additional compensation.  But how do we make it more lucrative to be a primary care physician?  Should the government more aggressively control compensation, as they do in Japan and Germany, to bring specialists and primary care physicians more into parity?  Should we offer additional support to medical students and residents who intend to go into high-need primary care roles?  Or should we recruit more nurse-practitioners who can take on many though not all of the functions of a primary care doctor?

Despite the potential for system-wide catastrophe, someone will be angry no matter which path we pursue.

3. Redefining Success in Health Care

One of the most enduring myths of the American health care system is that it’s the best in the world.  Well, we do have the biggest machines, the latest drugs, the most experimental procedures, and spend the most money.  Big Pharma regales us with tales about state-of-the-art drugs developed only in the U.S.  Technology companies talk about how their medical device has helped revolutionize medicine.  Heck, we have nearly twice as many MRI machines per 1 million people as any nation (except Japan).  But at the end of the day, those factors are anecdotal at best, completely irrelevant at worst.

Sure, we’re somewhat better in some cancer treatments and smoking cessation.  But those aren’t the metrics we should be using to define the best health care system in the world.  Instead, we should be looking at life expectancy, preventable deaths, infant mortality – all areas in which the United States dramatically lags behind other nations.  And that’s not even mentioning those in this country without access to affordable health care.

Health care isn’t Christmas morning.  Yet some still define success by who has the best toys.  It’s a fight that’s not going away.

4. Recognizing How Money Affects Medicine

When asked about a skill they’re familiar with, most people think they’re better than average – even though that’s mathematically improbable for all of them to be so.  So too, most health care providers think they’re immune from being heavily influenced by the role of money in medicine.  Health care workers and administrators are all too familiar with the hoops they have to jump through to provide quality health care for their patients in the face of insurance companies looking for a reason to deny their claims.  But that’s just part of the problem.

Think about the effect on prescriptions of that 5-minute visit from the pharmaceutical rep who leaves behind pens and notepads emblazoned with a pharmaceutical company’s logo.  Or how the constant need to see enough patients to be profitable alters the behavior of doctors.  Or how the fear of medical malpractice lawsuits influences doctors and hospital administrators and yields the practice of wasteful “defensive medicine.”

Many would say these factors are overblown.  Doctors would tell you that they’re intelligent enough to see through the sales tactics of the pharmaceutical companies.  Progressives would tell you that only 0.9% of all malpractice suits end in a jury verdict for the plaintiff.

But when pharma is investing as much as ever in face-to-face marketing, and when an average interaction between a doctor and a patient means the doctor only waits 23 seconds before interrupting… well, we’ve got a lot of ‘splaining to do.

5. The Continued Role of Private Insurance

The fight for universal health care is beginning to resemble a wrestling free-for-all.  In one corner, you have the insurance industry, which is willingly asking for increased government regulation, but thinks itself sufficient to insure all Americans, with no expanded or new public programs necessary.

In another, you have advocates for a single-payer system, for whom nothing less than the dismantlement of the for-profit insurance industry and the institution of a public “Medicare for All” system will suffice.

In still another, you have the supporters of the model espoused by Jacob Hacker, Barack Obama, Max Baucus, and Hillary Clinton, with a public system based on Medicare in direct competition with private insurance, which will either yield a more efficient private insurance industry, or a robust public plan that can ultimately evolve into a single-payer—or both.

In yet another, you have a new faction of conservative and progressive thinkers who think the problem lies with getting coverage from your employer, not whether the coverage is public or privately provided.  Their solution calls for the dismantlement of employer-based health coverage, empowering consumers.

In still another, you have free market purists for whom any government intervention in the industry is tantamount to “socialized medicine” (most people aren’t clear on what that means, but man, it sounds scary!)

Nothing fractures consensus on the need for health care reform like the role of private insurance.  A comprehensive solution will only involve one of the above approaches – and which one is truly anyone’s guess.