Sunday, March 18, 2018

Animal Farm Meets Health Care

In George Orwell's classic Animal Farm, the animals revolt against their human masters, and establish a classless society with the inspiring principle, "All animals are equal."  As events play out, their society devolves into a dictatorship with a ruling elite, and the principle becomes "All animals are equal, but some are more equal than others."

This, surprisingly, makes me think of health care. 

I am old enough to remember when maternity coverage was at best only very limited even in employer group health plans.  It took the Pregnancy Discrimination Act (1978) to require them to treat maternity the same as any "illness," and, even then, individuals plans often did not include it until ACA required it.  Similarly, coverage for mental health was typically skimpy until the Mental Health Parity Act (2008) required parity.

Preventive services were usually only available for (the small percentage of) people enrolled in HMOs, until network-based managed care plans grew more widespread in the 1990's.  The same happened with prescription drug coverage, which used to only be available to the minority of people with "major medical" coverage.

It took the Affordable Care Act to standardize what "essential benefits" should be included in health plans, and even then they are almost entirely medical benefits (and are still under attack, such as with "short term" health plans or Idaho's recent attempt to sell low cost plans). 

But, for the most part, medical services are generally covered by (most) health insurance plans.  For services like dental, vision, or hearing, not so much.   Evidently, some services are more equal than others.

We've managed to push our rate of people without health insurance to around 11%, but it's more than double that for dental insurance, and worse yet for vision coverage.  For seniors, the figures are significantly worse

The real question should be, why do we have separate coverages for services like dental or vision, especially when many lack them?

This matters.  According to NCHS, 14% of Americas report hearing trouble, 9% vision trouble -- and 7% have no natural teeth left (25% for those over 75).  There is a well documented link between oral health and our overall health, yet a study found that dental care had the highest financial barriers to care, compared to other health services.
Percentages of National Health Interview Survey respondents who did not get selected health care services they needed in the past 12 months because of cost, by age group, 2014.  Vujicic, et. alia.   
A third of millennials -- whose teeth one would expect to be good -- are reluctant to smile due to their teeth; 28% say it impacts their ability to get a job.  Poor oral health is most pervasive among low income people, yet only 17 states have Medicaid programs with comprehensive adult dental benefits, and the trend is to require that able-bodied people get jobs in order to qualify for Medicaid coverage.

Kind of a Catch-22.

We claim to support preventive services -- to the point ACA mandates coverage at no cost -- but that only applies to services that are medical in nature, performed by physicians.  If you want to get your eyes or your teeth checked, maybe you'll have some coverage for it, maybe it will even be covered at 100%, but, then again, maybe not to either.

Austin Frakt laments: "It’s an accident of history that oral care has been divided from care for the rest of our bodies. But it seems less of an accident that the current system hurts those who need it most."  Nicholas Kristof recounts that historical accident:
It’s virtually an accident of history that dental care isn’t considered part of medical care. The medieval barber-surgeon used to attend to all the human ailments that required a knife: bloodletting, tooth extraction, shaving. In the 1840s in the United States, the heirs to the tradition wanted to become professionals; they didn’t want to keep wandering from town to town selling their services. They asked physicians at the Medical College at the University of Maryland if they would include dentistry in the medical coursework, but the physicians refused. Soon after the dentists opened a separate dental school nearby.
And keep in mind, those weren't post-Flexner educated physicians.

If you break a bone, you'll see a doctor; if you break a tooth, you'll see a dentist.  If you have problems with your throat,you'll see a doctor; if you have problems with your gums, you'll see a dentist.  If you want to correct your vision with glasses, you'll see a optometrist; if you want to correct it with Lasik, you'll see a physician.

Think about the alphabet soup of "doctors" we have: M.D., D.O.s, D.C., Ph.D., PharmD, O.D., and D.P.M., and I've probably missed some. 

Specialization is understandable, as most physicians end up doing, but I have to wonder why some types of specialization start at the beginning of training, rather than after the basic medical training (see my previous article on balkanized medical education).

We accept all this because, well, that's the way it always has been.  That doesn't mean it makes sense, or that it is best for our health.

For example, the microbiome is a hot area of medical research and is starting to be an important option for treatments.  What if, say, microbiologists claimed only they could understand it and should be the only practitioners allowed to treat microbiome-related issues?  It would force us to guess when to see whom for what, but that is essentially what we've done with many other aspects of our health.

We each only have one body.  Although some health issues are fairly specific, we are increasingly realizing that many are systems issues involving multiple parts of the body.  It's time to stop drawing artificial distinctions between what care we get, who gives it to us, and how those professionals get trained. 

Health is not equal to health care.  Health care should not be limited to medical care.  We need to get past "historical accidents" and focus on what is best for our health, and our care.

Unless you actually do believe that all health services, and all health care professionals, are equal, but some are more equal than others.

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