There’s not much left to say about the Affordable Care Act/Obamacare that has not already been said.
The political left wants to repair it and the political right wants to repeal and replace it. Let’s take a step back and examine why it came into being in the first place. President Obama’s namesake act is the culmination of his administration’s efforts to reduce the number of uninsured Americans, provide Americans with affordable insurance premiums, and ultimately provide our population with better health outcomes; all admirable things for which to strive no matter which side of the aisle you’re on. Let’s examine the progress of these goals.
For a period of time in 2016, the number of uninsured Americans reached a low of 8.8%. As a point of reference, the pre-Obamacare rate of uninsured Americans was 16%. That equates to 20.4 million more people who are insured now. It is obvious that the goal of more insured Americans was reached. Regarding more affordable insurance, it seems that goal was not achieved. In fact, the opposite seems to be true. More and more of the cost is being shouldered by the healthcare consumer, or, our record numbers of insured Americans. While more Americans have coverage, many find themselves unable to meet sky high deductibles even for in-network service. Unfortunately, Obamacare does not achieve this goal.
The purpose of this piece is not to rehash the entire argument, though. There are components that work and others that do not. For what we want to focus on, it is necessary to look beyond politics. Then we can consider what it is that we really care about - and realize that no one is discussing it:
Does Obamacare or Trumpcare or any healthcare act help provide better health outcomes? The answer is mostly no.
It is universally accepted that healthcare has very little to do with health status or health outcomes – only about 10% of the total. This fact is accepted by all parties, left, right and center. In all the talk about healthcare, it is remarkable that no one talks about the real issue, which is the declining health status of Americans.
What does determine health status if not healthcare? In an increasing number of instances, the answer is “lifestyle.”
Unfortunately, in the US today, it is becoming more and more frequent that sickness is caused by the individual’s lifestyle choices. And in these cases, once you are sick “healthcare” cannot generally rescue you back to health, it can only – at best – somewhat diminish your degree of sickness. Often, good health will not be restored unless proper lifestyle choices are made and many health indicators are generally in decline. In fact, last year the mortality rate increased and the average life expectancy at birth decreased in America for the first time since 1993.
There are three primary lifestyle drivers of the bad and declining health of Americans as a society. All can be rectified by making proper choices and practicing self-discipline. They are, in declining order of importance:
1. HOW MUCH YOU EAT: Obesity is the principal driver of the decline in health status from all causes. Contrary to popular belief, obesity is almost entirely dependent on how much you eat. What you eat matters, but not anywhere near as much as the quantity you eat. Every category of disease: heart disease, diabetes, hypertension, cancer, stroke, arthritis, auto-immune disease and infection are worsened by obesity and the problem is continuing to worsen. Weight loss and proper weight maintenance mean eating less and dealing with being hungry – and we as a society have lost the will to do so.
Also, contrary to popular belief, it is well established in the scientific literature that exercise does not help weight loss. Exercise is important in its own right in improving health, but exercise is an appetite stimulant and virtually every study has shown that moderate exercise does not increase weight loss. Relying on exercise to lose weight is a prime cause of the continually worsening obesity epidemic. The reason is that people do not force themselves to endure the pain of eating less, which is required for weight loss because they think exercise while continuing to over-eat will do the job; it won’t. This Vox video is highly instructive in this regard.
2. SMOKING: Smoking, as everyone knows, is very dangerous to your health. Choosing to smoke is choosing to be sick.
3. SUBSTANCE ABUSE: Whether that substance is alcohol, a prescription pain killer, or a mind-altering drug, choosing to abuse drugs guarantees bad health.
Less important but still influential lifestyle determinants of good or bad health:
4. SLEEP: The average American slept 8.1 hours/night in the 1960s but sleeps only 6.9 hours per night now. Almost everyone needs 7 to 9 hours per night, and adolescents should have 9-10. Lack of sleep results in disease, and also, through alterations in the Leptin – Grehlin hormonal pathway, appears to promote obesity.
5. EXERCISE: Although it does not promote weight loss, exercise does promote good health in its own right, even if it is not nearly as important as the top three factors listed.
The next time you watch a debate on the merits of the various healthcare legislative plans, remember the following: no matter which plan is adopted, the overall effect on health will be small.
The real issue for debate should be about how to improve lifestyle choices. Education about lifestyle has utterly failed to modify behavior. Everyone knows we should not over-eat, smoke, and abuse drugs and alcohol, yet most of these activities are increasing. Technologies are available to help patients and providers monitor their habits over time, and the correct EHR can aid in improving outcomes, but these tools will not be fully utilized without adequate motivation. What we need are strong incentives, financial and otherwise, for people to exercise the self-discipline necessary to get healthier. The one lifestyle parameter that has improved is smoking, but it only happened after smoking became very expensive and often prohibited. Politicians should be advocating this tough love approach, standing up for the health of their constituents instead of being afraid to offend them. We have to move beyond strident talk about “healthcare,” while our declining “health status” and toxic lifestyle are treated to a deafening silence.
Dr. Prodromos is the President of Illinois Sports Medicine and Orthopaedic Centers, medical director of the Illinois Orthopaedic foundation and is an internationally recognized leader and innovator in Orthopaedic Sports Medicine. Click here for more information about Dr. Prodromos.
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