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Access to healthcare has become one of the defining issues of our time. While in many countries the fundamental challenge is how to provide basic healthcare services and deliver essential vaccinations, in the United States healthcare has become a political football where Congressional leaders fight about who should get health insurance and who should pay for it. What's missing from these discussions is a more fundamental question: what is healthcare for?
We are learning that our health is highly dependent on the social and environmental conditions in which we live and work. Air pollution, chemical exposure, poor quality food and poverty are all more predictive of health outcomes than our genetic makeup. Yet our healthcare system has largely ignored these factors when delivering healthcare. In the US, 70% of all healthcare expenditures are devoted to treating chronic disease, while only 4% are devoted to preventing it. This approach has led to the institutionalization of a sick care system that now accounts for 18% of the total economy. Outside of the military, healthcare is the largest part of the GDP.
Yet despite the fact that we spend more money than any other nation on healthcare, our health statistics lag behind most other industrialized countries. Our cancer rates are one in two men and one in three women. Obesity rates are approaching one in three Americans. Asthma is increasing in our youth. If we continue to focus largely on treating chronic conditions in individual patients, we will certainly help people live longer with their diseases but we will bankrupt the system in the process.
What if instead of spending most of our healthcare dollars of treating sick people, we pushed healthcare upstream to address the social and environmental conditions that make people sick in the first place? What would this look like?
First, we would change the place where healthcare happens. Rather than the acute care hospital, healthcare services would occur in communities – in schools, in workplaces, in pharmacies and libraries. We would help detox our homes, schools and factories and create the conditions for community wellbeing. We would also redesign our transportation systems to favor public transportation options. We would ensure that our communities had access to local and healthy food options so we could prevent obesity and diabetes, rather than treat people when it is too late.
Second, we would change the healthcare product. Imagine if doctors wrote prescriptions for fruits and vegetables rather than bariatric surgery and statins? What if we could access information on air pollution conditions on our smart phone and take precautionary actions on bad air days? Or instead of driving to our doctor's office, we e mailed her our concerns and she responded with a set of recommendations? Increasingly, mobile technology and inexpensive diagnostics are creating the ability to take greater control over our health and at a greatly reduced cost.
Third, we would expand who we consider a healthcare provider. Since we now understand that toxic housing conditions dramatically contribute to asthma attacks, we should be creating jobs for environmental auditors that can go into people's houses and remove moldy carpet and pesticides and provide residents with HEPA filters. This will reduce emergency room visits and related costs and also support an army of environmental auditors. In fact, there are 40 such programs like this already happening around the country. Similarly, we could be deploying college graduates to help desks in clinics to address the social care needs of patients like food and fuel assistance, daycare and violence prevention, rather than using valuable clinical staff time on issues where they have no expertise. There are many areas where we can expand our definition of healthcare providers and employ non-clinical staff to support healthy communities.
This brings us to the crux of the transformation required – changing payment incentives. As long as we pay for procedures rather than outcomes, we will continue to have escalating healthcare costs. The Affordable Care Act represents an important step toward capitated payments and not reimbursing hospitals for certain clinical-based mistakes. But we have a long way to go toward creating a system than is centered in prevention rather than treatment.
A preventative healthcare system would mobilize all its available financial and clinical assets to support healthier communities. This would include leveraging its purchasing power to drive sustainable supply chains and create green jobs in the community; deploying community outreach staff to reach people where they live and work, and becoming vocal messengers for protective policies that would rein in climate change, phase out toxic chemicals and incentivize a healthier food system.
In this next period of our history, healthcare will increasingly need to regard the community and the planet as the patient if we are going to move upstream and prevent the plethora of diseases that face us today.