 Confession
time. The reason for my late and sporadic postings over the last week
or so is that I pinched a nerve in my neck, and I've been doped up
since then. The choice of the Resilience topic for the Open Thread
during my absence was a bit ironic -- the injury came from doing
strenuous physical work (mowing and pushing my heavy scrub-cutter
around our very hilly lot), when I get almost no proper exercise of any
kind and have lousy posture. It's given me some time to think about our
troubled health care system, about why idiots like me get injuries like
this when we know better, and about a suggestion from several readers
that perhaps the solution to health care is to pay people for staying healthy.
The
idea has a kind of immediate provocative appeal, but I don't think it
can work. In the first place, systems that provide financial rewards
for staying healthy (like some insurance schemes) don't actually reward
you for staying healthy, they reward you for not seeking medical help and for not filing claims,
which is not the same thing at all. This is the same perversity that
encourages people who are victimized by vandals from not filing a
perfectly justifiable insurance claim because they know their insurance
premiums will then rise by more than the amount of their claim. This is
a depraved but very profitable way to run an insurance business. As a
means of providing equitable and functional remedy for accidents,
illness or injury, it is horrific. It unquestionably results in
unnecessary and avoidable human death and misery, overwhelmingly to the
poor and weak, simply out of the fear of economic penalty.
Some
organizations offer standard "sick days" each year that you get as
extra vacation days (or as a monetary bonus) if you're not sick. The
consequence of this is to treat sickness as a kind of crime that you
get rewarded for not committing. It assumes what Malcolm Gladwell has called
"the Moral Hazard Myth" -- that whenever you offer insurance for
something, it automatically leads to rampant abuse. In other words,
that people -- especially the poor, weak, and unemployed -- are lazy
exploiters of public largesse. Organizations I know that have tried
"sick day" policies ended up with sick people coming to work, spreading
their illness and doing poor quality work because of it, so they could
"save up" their sick days for extended vacation.
Insurance
companies have also tried, in a superficial and sloppy way, to reward
people for avoiding behaviours that cause illness (like having premiums
for smokers that are twice those for non-smokers). The general
consequence of such policies is (a) it encourages addicts to lie, and
(b) it encourages insurance companies to spy on people so they can
catch people lying so they can keep the premiums but not have to pay
any claims. Great system, huh.
The problem with all such
schemes is that it is impossible to say when an illness is the result
of hereditary factors (genetic predisposition), when it is the result
of environmental exposures (in the home and workplace and society at
large), and when it is the result of behaviours over which the patient
has (according to some philosophies, anyway) some degree of control.
Or, to put it another way, it's impossible to say when and to what
degree it's the patient's fault they were sick or injured.
So
while the idea of paying people to stay healthy appeals to me in a wry
kind of way, I think it is basically an unworkable idea. So what might
work better? Are there other ways, other than financial bribes and
penalties, that can actually change behaviour in a way that will make
people healthier?
There's a company in our community that
provides a free, supervised exercise facility to all its employees, and
a subsidized cafeteria that offers only healthy foods. I think they're
on the right track -- they're rewarding behaviours that repay them as
an employer (through healthier, more resilient workers), without
getting specific about who's to blame when an individual becomes sick
or injured. It's a 'no fault' system.
What is needed to
supplement this is more honesty in our society and our economy about
many of the things that are bad for our health, but which are very
profitable, and which therefore are rarely recognized or addressed as
the social evils they really are. Alcohol, for all its benefits, sucks
billions out of the economy in death and violence and injury and
illness every year, yet we still tolerate advertisements that show its
consumption as an essential ingredient of personal happiness. The
meats, and many other foods we eat that are advertised to the hilt
(especially the fat, salt and sugar-laden "fast-food" varieties) are
chemical cesspools that unquestionably add billions of dollars to
annual health care costs.
The real answer, I would argue, is not
rewarding people for staying healthy (because we can never determine
when their health or lack of it is due to their behaviour or factors
beyond their control), but rather health care innovations that address the real, preventable causes of illness and injury:
- Discovery and provision free of charge of safe substitutes for the substances to which we are addicted,
including salt, refined sugars, starches, nicotine, alcohol, and
opiates (and perhaps even some hormones and chemicals produced by our
own bodies during addictive behaviours like gambling, pyromania and
violent abuse of others). I think the record shows that it's futile to
get us "unaddicted" by the use of will power, counseling, therapy and
various reward and coercive programs. Such programs only work for a few
people, and they are temporary and fragile. Let's acknowledge the power
of the monkey, that he has us all in his grasp, and that the best we
can do is find substitutes for our addictions that don't cause the
social, physical and psychological damage that the toxins we're now
hooked on do. That means we need to stop rewarding the companies that
profit, outrageously, from our addictions, and make them responsible,
if they want to stay in business, for helping us find (and fund) the
'cures' for these addictions.
- Development of easy exercises that can be done while doing other "productive" work.
For example, perhaps PCs powered by silent hand-cranks or foot-pedals
could not only give the sedentary some much needed exercise, but also
help conserve non-renewable energy resources at the same time. Our
bodies are meant to be moving, and natural physical activity is
essential to resilience, to keep us free from illness and injury. As
long as it's more fun and more profitable to be physically inactive
than active, that's what we will be. We need to make it easy to be fit,
so we don't need to "make time" for it, but instead become fit in the
normal course of doing everything we do. This will require some great
ingenuity, but we've solved much greater problems.
- Making prevention, self-diagnosis and self-treatment of illnesses and accidents free and easy.
Today we're discouraged by lawyers, by corporations, and by governments
trying to justify their expensive centralized infrastructure, from
taking responsibility for and care of our own bodies. Take away those
barriers, and make it easy for us to track our own health and fitness,
and look after ourselves, and we'll tap into the collective wisdom of
six billion instead of relying helplessly on the spotty and
overstressed knowledge of 'professionals'. But it has to be free, and
accessible to all. And it would come with a catch: We would have to
legally accept responsibility for our own health, and not look for
people to sue for billions of dollars when (as will inevitably happen
to some of us) the collective wisdom is inadequate, or just plain
wrong. We have to learn from our mistakes, and to do so we have to have
permission to make them.
We cannot expect those with vested
interests in the current health care system to reform it. We need to
create our own organizations to develop, in Open Source form, these
three types of health care innovation. We will have to do battle with
the lawyers, corporations, politicians and preachers and some medical
practitioners, who will not yield power of the current massive,
extravagant and dysfunctional system easily. But like all disruptive
innovation, our work in these three areas will be subversive. The
regular health-care system won't know it's been rendered obsolete until
it's too late. And there are many in the existing health-care system
who recognize the need for these innovations and the distress of the
current system, who will be more than willing to join us in making the
new, responsible, patient-centred system work. |
MADE IN CANADA
trust your
instincts 
