....."The biggest problem with healthcare policy may be that those who design healthcare policy mostly design it for people who design healthcare policy.".....
NOW
Substitute for "healthcare" any policy designed or implemented, or both, by GOVCO (my shorthand for every level of government or "governance" (ie big business or NGOs) and you have articulated the "IRON-RULE of The Way the World Works". At least for today. Tomorrow it may stop working at the rate we're going. And then the "Graboyes Iron Rule" will wind up on the ashheap of history.
Robert, Excellent summation and analysis but it begs the question: what can we as physicians do about it? I have always tried to counsel and advise my patients in healthy lifestyles, healthy eating, managing stress, etc. etc. but even though I am old school, see every patient, and spend much more time with them than the average primary physician (I am a specialist), it amounts to no more than 45-60 minutes in two or three visits over several months, most of which time is devoted to the specific problem they come to me with. I don't have answers either, but to think we are going to make a dent in obesity and chronic disease by targeting the fifty-something who is obese, already diabetic, and hypertensive is a fantasy. We need to restore some common sense policies and target the next generation. Restoring outdoor recreation in schools for kids, teaching nutrition to the young, and at least making an effort to get them off of their screens would be a start. How do we restore unstructured play, such as was the norm on my own childhood. Grownups must model healthy behaviors, especially doctors (my partner is obese-imagine how effective his advice to his patients to lose weight is). I fear I am a pessimist because I know human nature craves creature comforts and it is the unusual person who goes out of their way to be uncomfortable, i.e. exercise when they don't feel like, refrain from stuffing their face when confronted with a smorgasbord of tasty food, and resist that second or third drink. Rick
After working in Home health as a physical therapist for 10 years you come to realize that Yes you have very little sway over what you can do to change a person’s overall health.
For the policy wonks, I would recommend they spend a year doing just home health visits. They would see the limitations of the mentioned policies. Gym memberships, tax credits, yoga breaks and even 100% governmental subsidized arugula distribution to all citizens won’t help. The variables are too numerous and behaviors are too in bedded.
Specific issues can be addressed for an immediate health problem. But the fact that I saw people on a frequent basis for the same problem confirms the inability for most people to change even with repeated education.
> The biggest problem with healthcare policy may be that those who design healthcare policy mostly design it for people who design healthcare policy.
See also: open-source software. With a very few notable exceptions such as web browsers, almost all of it is built by software developers to solve their own very specific needs, which is why it's often a poor fit for things the general public wants to do.
I recently had the opportunity to advise a younger, healthy family member just starting out in life who needed to purchase health insurance. Before this, I never had much reason to really think about health insurance other than picking from the menu of choices offered by a corporate employer. My experience validates your thesis to a "T."
Putting aside employer sponsored plans, health plans fall into two broad groups.
The first is the "Obamacare Compliant" plans. These are characterized by high deductibles, high coverage limits, and higher premiums. They make a lot of sense for higher earners who aren't terribly concerned about going out of pocket to cover routine needs like their kids' strep throat. Their high coverage limits provide a backstop in case things really go off the rails for something like a cancer diagnosis or a kidney transplant. It would also seem that these plans great sense from a health care system cost containment standpoint. Not coincidentally, these structures fit the needs of the kind of people that develop health care policy. One might call them "Rich People" plans.
The second are what I will call "Normal People" plans, for lack of a better term. These plans are characterized by lower deductibles, lower coverage limits, and lower premiums. They make a lot of sense for someone who might otherwise have to choose between having their sprained ankle looked at or making their next car payment. Normal People plans provide a day-to-day backstop for people don't have wealth to protect in the case of a catastrophic event. This second type of plan is actually illegal in a number of states.
My family member would have opted for the second type of plan. Had I been in their position, I would have done the same. But knowing that I was going to be the bankroll in any event, I opted for the first type.
An apt example of what Prof. Graboyes refers to would be the Healthy, Hunger-Free Kids Act of 2010. Its object was to improve the standards of lunches and breakfasts served in government schools. In particular, it required more fresh fruit and vegetables. The Act was largely designed by Michelle Obama and passed by the Congress, none of whom eat in school cafeterias. By 2014, a study by the Harvard School of Public Health reported that students under the program threw away 60% of the vegetables and 40% of the fruit.
It's all the grains and carbs and ultraprocessed oils. We raise people like my uncle's hogs. He wouldn't touch corn or as he called it 'pig food'. We've raised a nation of hogs.
As an internist/pediatrician who largely deals with uninsured/underinsured people, I want to comment about my 21 years of experience with the “asphalt crew” types. I do a lot of DOT physicals. My income is considerably lower than that of my colleagues as I am self employed by choice and thus NOT personally receiving the health related benefits mentioned in your article.
First, only giving advice which I am personally able to follow has made me focus on what is practical. Taking as much self control out of the equation as possible is a good starting point. My top dietary recommendation is “only use the small plate and the small bowl.” I am glad to report that this is something which has been effective for gradual weight loss in a surprisingly high proportion of my clientele. Those who adopt this lose weight typically at a rate of 2-5 lbs. per year, and keep it off. My second dietary suggestion is to avoid calories in beverage form. The chronic soda drinkers who switch to water typically lose about 10lbs. in the first year.
Second, not all health problems are caused by lifestyle. You can’t control your heredity and it appears that which bacteria reside in your gut has an outsized impact on health risks. I have seen people smoke and drink their way into their 80s, and nonsmokers develop heart disease in their thirties.
Third, the role of oral health in disease prevalence is largely ignored, but something with the potential to have an enormous impact. It’s expensive to care for teeth out of pocket if you’re in need of professional help. This is an issue for most people who lack dental benefits, as well as those who have them but can’t use them due to work hours or distance constraints.
Ultimately we need to stop looking for utoipia in health care, and focus on doing what we can. I see plenty of people who cannot be helped. It’s frustrating but health care policy wonks need to factor that in. I get tired of people who aren’t in the trenches pontificating about this stuff.
There’s plenty of room in the trenches, though, for anyone who wants to jump in. Ivory towers are so confining…
I believe this was also a strong theme running through "The Bell Curve" by Murray and Herrnstein, with respect to the justice system, that is, that the justice system is designed by people (lawyers, legislators, judges) to work for people like themselves -- who, of course, are almost never its "clients." Consequently, for the people who actually become enmeshed in it, its systems of motivations and its general machinery are baffling, ineffective, in turn laughable and horrific, and its outcomes far more mediocre than the theory of its designers would suggest. I found this a very persuasive point of view. It doesn't surprise me at all that it should apply to the socialized aspects of medicine -- or old age medical care and pensions, while we're at it.
....."The biggest problem with healthcare policy may be that those who design healthcare policy mostly design it for people who design healthcare policy.".....
NOW
Substitute for "healthcare" any policy designed or implemented, or both, by GOVCO (my shorthand for every level of government or "governance" (ie big business or NGOs) and you have articulated the "IRON-RULE of The Way the World Works". At least for today. Tomorrow it may stop working at the rate we're going. And then the "Graboyes Iron Rule" will wind up on the ashheap of history.
But until then...
"fall consensus effect"? Could this be a wrong-word error for "false consensus effect"?
Yep. Arugula arrives well before the asymptote runs out.
I’m beginning to warm up to this mid journey thing. The illustration is priceless.
Robert, Excellent summation and analysis but it begs the question: what can we as physicians do about it? I have always tried to counsel and advise my patients in healthy lifestyles, healthy eating, managing stress, etc. etc. but even though I am old school, see every patient, and spend much more time with them than the average primary physician (I am a specialist), it amounts to no more than 45-60 minutes in two or three visits over several months, most of which time is devoted to the specific problem they come to me with. I don't have answers either, but to think we are going to make a dent in obesity and chronic disease by targeting the fifty-something who is obese, already diabetic, and hypertensive is a fantasy. We need to restore some common sense policies and target the next generation. Restoring outdoor recreation in schools for kids, teaching nutrition to the young, and at least making an effort to get them off of their screens would be a start. How do we restore unstructured play, such as was the norm on my own childhood. Grownups must model healthy behaviors, especially doctors (my partner is obese-imagine how effective his advice to his patients to lose weight is). I fear I am a pessimist because I know human nature craves creature comforts and it is the unusual person who goes out of their way to be uncomfortable, i.e. exercise when they don't feel like, refrain from stuffing their face when confronted with a smorgasbord of tasty food, and resist that second or third drink. Rick
After working in Home health as a physical therapist for 10 years you come to realize that Yes you have very little sway over what you can do to change a person’s overall health.
For the policy wonks, I would recommend they spend a year doing just home health visits. They would see the limitations of the mentioned policies. Gym memberships, tax credits, yoga breaks and even 100% governmental subsidized arugula distribution to all citizens won’t help. The variables are too numerous and behaviors are too in bedded.
Specific issues can be addressed for an immediate health problem. But the fact that I saw people on a frequent basis for the same problem confirms the inability for most people to change even with repeated education.
> The biggest problem with healthcare policy may be that those who design healthcare policy mostly design it for people who design healthcare policy.
See also: open-source software. With a very few notable exceptions such as web browsers, almost all of it is built by software developers to solve their own very specific needs, which is why it's often a poor fit for things the general public wants to do.
I recently had the opportunity to advise a younger, healthy family member just starting out in life who needed to purchase health insurance. Before this, I never had much reason to really think about health insurance other than picking from the menu of choices offered by a corporate employer. My experience validates your thesis to a "T."
Putting aside employer sponsored plans, health plans fall into two broad groups.
The first is the "Obamacare Compliant" plans. These are characterized by high deductibles, high coverage limits, and higher premiums. They make a lot of sense for higher earners who aren't terribly concerned about going out of pocket to cover routine needs like their kids' strep throat. Their high coverage limits provide a backstop in case things really go off the rails for something like a cancer diagnosis or a kidney transplant. It would also seem that these plans great sense from a health care system cost containment standpoint. Not coincidentally, these structures fit the needs of the kind of people that develop health care policy. One might call them "Rich People" plans.
The second are what I will call "Normal People" plans, for lack of a better term. These plans are characterized by lower deductibles, lower coverage limits, and lower premiums. They make a lot of sense for someone who might otherwise have to choose between having their sprained ankle looked at or making their next car payment. Normal People plans provide a day-to-day backstop for people don't have wealth to protect in the case of a catastrophic event. This second type of plan is actually illegal in a number of states.
My family member would have opted for the second type of plan. Had I been in their position, I would have done the same. But knowing that I was going to be the bankroll in any event, I opted for the first type.
A practical application of your thesis at work.
An apt example of what Prof. Graboyes refers to would be the Healthy, Hunger-Free Kids Act of 2010. Its object was to improve the standards of lunches and breakfasts served in government schools. In particular, it required more fresh fruit and vegetables. The Act was largely designed by Michelle Obama and passed by the Congress, none of whom eat in school cafeterias. By 2014, a study by the Harvard School of Public Health reported that students under the program threw away 60% of the vegetables and 40% of the fruit.
Metabolic researchers at this Swiss Re conference share recent research on the metabolic origin of most chronic disease. https://www.swissre.com/institute/conferences/fixing-metabolic-health.html
It's all the grains and carbs and ultraprocessed oils. We raise people like my uncle's hogs. He wouldn't touch corn or as he called it 'pig food'. We've raised a nation of hogs.
As an internist/pediatrician who largely deals with uninsured/underinsured people, I want to comment about my 21 years of experience with the “asphalt crew” types. I do a lot of DOT physicals. My income is considerably lower than that of my colleagues as I am self employed by choice and thus NOT personally receiving the health related benefits mentioned in your article.
First, only giving advice which I am personally able to follow has made me focus on what is practical. Taking as much self control out of the equation as possible is a good starting point. My top dietary recommendation is “only use the small plate and the small bowl.” I am glad to report that this is something which has been effective for gradual weight loss in a surprisingly high proportion of my clientele. Those who adopt this lose weight typically at a rate of 2-5 lbs. per year, and keep it off. My second dietary suggestion is to avoid calories in beverage form. The chronic soda drinkers who switch to water typically lose about 10lbs. in the first year.
Second, not all health problems are caused by lifestyle. You can’t control your heredity and it appears that which bacteria reside in your gut has an outsized impact on health risks. I have seen people smoke and drink their way into their 80s, and nonsmokers develop heart disease in their thirties.
Third, the role of oral health in disease prevalence is largely ignored, but something with the potential to have an enormous impact. It’s expensive to care for teeth out of pocket if you’re in need of professional help. This is an issue for most people who lack dental benefits, as well as those who have them but can’t use them due to work hours or distance constraints.
Ultimately we need to stop looking for utoipia in health care, and focus on doing what we can. I see plenty of people who cannot be helped. It’s frustrating but health care policy wonks need to factor that in. I get tired of people who aren’t in the trenches pontificating about this stuff.
There’s plenty of room in the trenches, though, for anyone who wants to jump in. Ivory towers are so confining…
Yup. Best predictor of health outcomes is zip code.
I believe this was also a strong theme running through "The Bell Curve" by Murray and Herrnstein, with respect to the justice system, that is, that the justice system is designed by people (lawyers, legislators, judges) to work for people like themselves -- who, of course, are almost never its "clients." Consequently, for the people who actually become enmeshed in it, its systems of motivations and its general machinery are baffling, ineffective, in turn laughable and horrific, and its outcomes far more mediocre than the theory of its designers would suggest. I found this a very persuasive point of view. It doesn't surprise me at all that it should apply to the socialized aspects of medicine -- or old age medical care and pensions, while we're at it.