The 2012 elections showed that our country is almost equally divided on the role of government versus personal responsibility. Central to this tug o war has been Obama care (Patient Protection and Affordable Care Act), the biggest overhaul of the US health care system since Medicare and Medicaid in 1965. Obama care's primary aim is to reduce health care costs by increasing the number of insured Americans. It will increase coverage by including mandates, subsidies and tax credits to both employers and individuals over the next 8 years.
My criticism of Obama care is that it doesn’t address the demand for health care. Increasing the supply of health insurance is only half the problem. US health care costs totaled $2.6 trillion dollars in 2010. The CDC estimates that about 75% of those costs can be attributed to chronic diseases such as diabetes, cardiovascular disease, strokes and cancer. That's $2 trillion dollars spent annually on treating chronic diseases. In our current health care model, individuals expect that as they grow older they will have to rely on medicine, surgery or other invasive treatments against chronic diseases. Imagine the outcome on health care costs if Americans took greater personal responsibility for their own health by implementing healthier lifestyles such as not smoking, not being overweight, being physically active and eating more fruits and veggies and less meat. Imagine that these changes could reduce the occurrence of chronic diseases by 50%, a savings in health care costs of $1 trillion dollars.
I propose that Obama care is amended to provide tax credits to individuals who achieve target goals for good health markers such as low BMI scores (ratio of weight in Kg over square of height in m^2), low cholesterol scores, low blood pressure and nicotine/drug testing. Tax credits will financially motivate Americans as they age to prevent chronic diseases by making better lifestyle choices, and the huge savings in health care costs will outweigh the cost of the tax credits.
An argument against this proposal that I want to address is the family tree. It goes like this, “My parents and grandparents had chronic diseases. Making better lifestyle choices isn’t going to help me. It’s in my genes.” There’s likely some truth in this argument, but how much effect can a healthy lifestyle really have on preventing chronic diseases? A recent TEDx presentation addressed this question. One of the primary references was a journal article which was coauthored by doctors from the CDC and the German Institute of Human Nutrition. The article reported findings from the EPIC study (European Prospective Investigation Into Cancer and Nutrition) about the role of lifestyle choices on chronic diseases.
The EPIC study tracked 4 healthy lifestyle factors and 4 chronic disease responses of over 23,000 German men and women between 35-65 years of age from 1998 to 2006. Each participant was either ranked as healthy (1 point) or not healthy (0 point) for each of these lifestyle factors:
4 Lifestyle Factors
· 1 point = never smoking
· 1 point = BMI < 30 (ratio of weight in Kg over square of height in m^2)
· 1 point = physical activity > 3.5 hours per week
· 1 point = healthier diet above median of the population
Less than 5% of participants had 0 lifestyle points, about 35% had 2 points and nearly 10% had 4 points.
About half of the participants never smoked and one third had more than 3.5 hours of weekly physical activity. More than 80% of the participants had BMI scores <30.
The healthy diet factor was the most ambiguous. Participants reported on a food frequency questionnaire the number of grams intake daily for fruits and veggies, whole grain bread and meat. The mean and standard deviation of each food categories’ gram intake was determined so that each participant was given a z score = [value - mean]/standard deviation. The three z scores were combined in such a way that eating more fruits and veggies and whole grain increased the z score and eating less meat increased the z score. Median scores (intake grams) were not reported, so it was not specific what kind of diet was considered healthy, other than a diet dominated by fruits, veggies and whole grains.
Other potential confounding factors were taken into account. The data set was adjusted for age, sex, education and occupational status. Data was also collected on the following variables, but were determined not necessary for adjustment: marital status, number of adults and children living in the household and alcohol consumption.
4 Chronic Disease Responses
· Heart Attack
Risks for chronic diseases were calculated relative to the baseline of participants who had 0 healthy factors. Participants who had:
· 1 healthy factor reduced their risk of chronic disease by 49%
· 2 healthy factors reduced their risk of chronic disease by 63%
· 3 healthy factors reduced their risk of chronic disease by 72%
· 4 healthy factors reduced their risk of chronic disease by 78%
However, not all chronic diseases responded the same way to healthy factors. Diabetes was the most preventable chronic disease while cancer was the least preventable chronic disease. Participants who had 4 healthy factors:
· reduced their risk of diabetes by 93%
· reduced their risk of heart attack by 81%
· reduced their risk of stroke by 50%
· reduced their risk of cancer by 36%
Similarly, not all healthy factors had the same effects on reducing the risks of chronic diseases. Not being overweight (BMI < 30) had the greatest effect while a healthy diet had the least effect.
· BMI < 30 reduced overall risks by 57% (greatest effect on diabetes)
· Never smoking reduced overall risks by 33% (greatest effect on heart attacks)
· Physical activity > 3.5 hrs/wk reduced overall risks by 24%
· Healthy diet reduced overall risks by 21%
I think the results of these relative health factor risk rankings should be viewed with skepticism. The two greatest measured effects, BMI and smoking, were easily determined and the most accurate. Physical activity and healthy diet were estimated by the participants. If I were asked about those two health factors during the last 8 years of my life, the physical activity would be a rough estimate and healthy diet would be a guess. Even if the participant kept a food journal for 8 years, it's doubtful that they could accurately estimate the grams of each food group, and it's very unlikely that their diet didn't vary over 8 years. This skepticism is also fueled by the result from the combination of physical activity and healthy diet. Participants who had just those 2 healthy factors reduced their risk of chronic disease by 66%, up from 21% and 24% for each of these health factors separately.
Comparisons to Other Studies
The risk reductions of chronic diseases have been observed in other studies with similar health factors and similar results:
· Nurses Health Study (84,000 participants) reduced risk of heart disease by 83%, reduced risk of stroke by 79% and diabetes by 91%.
· Women's Health Study (36,000 participants) reduced risk of stroke by 55%.
· Health Professional's Follow-Up Study (43,000 participants) reduced risk of heart disease by 87% and reduced risk of stroke by 69%.
· Atherosclerosis Risk in Communities Study (16,000 participants) reduced risk of heart disease by 35%.
The EPIC study showed that adapting just 1 healthy lifestyle will reduce the risk of chronic disease by 50%. This is low hanging fruit. Adapting 4 healthy lifestyle factors reduced risk by nearly 80%. The challenge to achieve these results and drastically cut health care costs is to persuade Americans to make these changes. Americans have become too reliant on advanced treatments. There needs to be a paradigm shift towards simple preventions. Obama care could be that paradigm shift if tax credits for good health markers like low BMI, low blood cholesterol, low blood pressure and no smoking/drugs were added to encourage the reduction of health care demand while widening the pool of insurance supply.
How much should the tax credit be? Given the total costs of chronic diseases at $2 trillion and that there are roughly 100 million Americans with chronic disease, America is spending on average $20,000 per patient. Take 10% or $2000 to apply to tax credits. Even in the unlikely scenario that every American taxpayer (about 200 million) was motivated and achieved good health, that’s $400 billion dollars, much less than the $2 trillion dollars spent on health care today. And the positive impact on improving the nation’s health through prevention instead of treatment is priceless.