A Vision for Obamacare

Let's take a trip into the hypothetical United States of the future where the Affordable Care Act has transformed the health care industry* into one whose prime interest is health. In this election year, driven by hope of meaningful health care reform under a Supreme-Court-sanctioned Affordable Care Act, I've been thinking about how health care would look if health promotion (a goal not usually emphasized by the leaders of our medical-industrial complex) were as highly valued as illness treatment.

I realize my fictional health promotion system is a dream. I know that heroics and the swift, tangible gratification they provide are often chosen by human beings over the weak satisfaction of making something not happen. But, then again, fantasies can help us set goals. So here's my foolish, wacky, silly, naive, childlike, unrealistic list of what would happen in a reformed U.S. health promotion system, in no particular order, drawn from 30 years of observing health care: 

• First, no one would wait until after their coronary artery bypass graft operation or their heart attack to get a referral to cardiac rehabilitation. Ditto for pulmonary and post-cancer rehabilitation. And how about we start a rehabilitation program for everyone, not just those with certain diseases?  Structured rehabilitation programs work for people who benefit from social interaction combined with healthy lifestyle education and exercise. These programs also relieve fears about exercise (in other words, people with heart and lung disease learn that exercise is safe for them.) 
• The ACA would not permit payment for drugs not shown to promote health. Drugs have to pass safety trials and to do what the drug manufacturer is claiming they will do. That claim, unfortunately, does not have to be a genuine health outcome. An example is statin drugs, ubiquitously prescribed to reduce cholesterol, and they do this just fine. Data, however, are lacking as to their ability to prevent any meanginful health outcome such as death, bothersome symptoms, diminished quality of life, increased costs, and functional decline. They have not been shown to prevent first heart atttacks, the indication for which they are most widely prescribed. In the future, the $69.5 million paid by the 24 million users of statins in the U.S. would have to be shown to make a difference to the individual and societal experience for the drug to be covered by insurers. Otherwise, it's just smoke and mirrors, isn't it?
• Consumers would be informed. This means that people undergoing chemotherapy would not be surprised to find that hair loss is the least of their side effects. Disabling fatigue is the most common cancer treatment symptom, but people do not know this before they start chemo. Other side effects of which they not warned include infertility, depression and instant menopause for even young women. In my fictional health promotion system, everyone, no matter who, would understand the benefits and risks of their treatment regimen before one molecule of drug enters their body. This would necessitate skilled educators explaining, demonstrating and showing patients what to expect as many times as it takes, for as long as it takes, using many different methods.
• Ditto for surgery. Relying on surgeons to do the explanation of risks and side effects is the fox guarding the henhouse. Especially given the way their self-worth has been confounded by their patients' "success." (Watch starting at 10:47.)
• Just as my mail-in pharmacy phones me to remind me when it's refill time, people would be reminded by phone and email when their children need vaccinations, when they need that regular screening physical or colonoscopy, when to visit the dentist, when to get an eye exam, and so forth. We are overcome by information and demands on our time - the health care system must help people put priority on health maintenance, or it is forgotten.
• Vitamin deficiencies are 100% preventable. A once-daily multivitamin for every citizen should be covered by the health care system. Calcium for women, too.  Both of these are cheap. 
• Not-for-profit public exercise clubs with group classes would be available to every citizen for a small fee per visit. For personal trainers, we would pay out of pocket. 
• Every person could call a single toll-free number to get health coaching by a nurse or person with a degree in health education (i.e., people who are educated to do this well). The program would not be linked to employers or insurers in any way. Because I suspect assurances of confidentiality from employers who dole out discounts for taking part in insurance-company-run health improvement programs do not convince everyone. The bachelor's-prepared registered nurses and health educators who answer the lines would perform a focused health interview and use evidence-based strategies to help people live healthier lifestyles. No guilt; no blame; no overwhelming demands to fix everything at once. No idiotic "You should lose weight" to someone who has struggled their whole life with obesity. (I kid you not -  I hear this from physicians; they do not know how to do health coaching. They do get paid to do it, however.)  

* Industry may not be the most apt noun because most of our health care costs are paid in public systems, primarily Medicare and Medicaid. I prefer industry vs. system because there really is no system; we have more of a mish-mash of systems.