Sunday, August 16, 2009

The Whole Foods Alternative

The Whole Foods Alternative: Organic Produce (and Health Insurance Reform) for those who can afford it.

By Aaron Fox, MD

National Physicians Alliance


Wasn’t it just last year that we heard from political pundits that arugula munching Barack Obama was out of touch with average Americans.  Well apparently John Mackey, CEO and co-founder of Whole Foods Market, not only shares President Obama’s concern with the price of arugula but also the price of health care in America.  In a Wall Street Journal op-ed piece, he shares an eight point plan for controlling health care costs, some of which is derived from his own experience in providing health insurance for his employees.  His plan includes promoting high deductable health insurance plans, deregulating health insurance markets and strengthening the individual market, and solving the problem of 46 millions uninsured Americans through charity.  Well sorry, Mr. Mackey, like many of the luxury goods at Whole Foods Market, your health reform ideals are out of touch with the lives of many Americans.


High deductable health insurance plans, or consumer directed health reform, where individuals are responsible for the first $1,000 - $2,500 of health care that they consume (not including premiums) and the insurance company covers catastrophic care, is not a new innovation introduced by Whole Foods and other forward thinking entrepreneurs.  These plans have been around for decades, and while they are certainly less expensive than comprehensive health care benefits, evidence so far shows that they have only had a moderate effect on controlling costs and their impact on quality of care is unknown. 


Unlike CEO Mackey, as a physician, I am not just worried about health care costs, but also the quality of care for my patients.  In the 1970’s, the RAND health insurance experiment studied the impact of different types of health plans, including free care and plans where patients had increasing levels of responsibility for the costs of their care.  Families who were randomly assigned to higher levels of cost sharing consumed less health care than those receiving free care, but they did so by avoiding both necessary and unnecessary care.  For the poorest families, going without care may have saved money, but it also had a real health impact.  In just a decade, it was estimated that the option with free care reduced deaths by 10% for patients with hypertension and low socioeconomic status.  While high deductible plans are attractive to the young and healthy, like those who work at Whole Foods markets, we need to provide high quality health care that is affordable to everyone, especially those who are sick and struggling economically.  In a review of consumer directed health care reform, including high deductible plans with health savings accounts, health economist M. Gregg Bloch, “if consumer-directed plans achieve market dominance, disparities in care by class and race will probably grow.”  


Case in point, this week I saw Ms D, who works as a mental health counselor and receives health insurance through her employer.  Her plan covers office visits, but she has high co-pays for her medications, which she cannot afford.  Her blood pressure and cholesterol have been very elevated, and she requires medication to reduce the risk of heart attack and stroke.  This past visit her blood pressure was great, but her cholesterol had not responded to medications, so I inquired more.  It turns out that she chose to purchase the blood pressure medications because they are cheaper.  While empowering patients in health care decision making is a noble intention, my patient’s decision is one that no one should have to make.


Mr. Mackey uses his op-ed forum to criticize socialized medicine and emphasize personal responsibility, but creating a dichotomy where “government controlled” health care is bad and individual health care decisions are good serves more as a political tool for inciting rage, rather than a model to improve our current dysfunctional health care system.  The bill being debated in the House of Representatives is a compromise between a single payer government plan and one that favors private health insurance, and it seeks to improve the health care system not make a political point. 


I agree with Mr. Mackey’s emphasis on healthful living and disease prevention, but not everyone can afford to shop at Whole Foods and purchase organic produce.  I recommend a healthful diet to all my patients, and many tell me that fresh fruits and vegetables are either too expensive or unavailable in the local convenience shops or “bodegas” where they do most of their shopping.  To respond to the need for affordable produce, the City Council and Department of Health in New York City have developed programs to promote green markets throughout the city and provide incentives where food stamps recipients can use their benefits cards to purchase fresh produce and healthful foods.  Sometimes, the government can do good, and there are provisions for strengthening the federal public health infrastructure within the House health reform bill.


In terms of increasing health care costs, one of the problems shared by both Medicare and private insurance is expanding use of new technologies, and the perverse incentives for doctors to provide more care whether it is beneficial or not.  The House proposal seeks to address these perverse incentives, first, with its funding of comparative effectiveness research, which would help doctors understand which treatments and technologies are of high value, and second, with its Medicare reimbursement reforms, which would pay doctors for improving health outcomes not simply for performing procedures.  To control growth in health expenditures, we should be making it easier for people to access high value care while limiting payment for care with limited or no value.  For example, cutting co-payments for extremely effective cholesterol lowering medications could save $1 billion per year by preventing patients from skipping doses due to costs and therefore preventing heart attacks and strokes.  Sometimes providing free care SAVES MONEY. Patients should also be involved in deciding what care is of high value, but suggesting that a patient with cancer could rationally decide what care is worth the costs is unrealistic. 


Socialism and personal responsibility are value laden terms, but we should not let our ideology get in the way of reform that would improve the lives of millions.  Charity is a nice idea, and Americans are very giving in times of need, but patients should not have to grovel for health care when they are sick; healthful living and prevention is a must, but there are millions of people in need of immediate medical care and who have no means to pay for it; the argument over the “right” to health care has already been decided - people cannot be turned away from emergency rooms if they are ill.  Now, we need to create a rational health care system that serves all Americans, emphasizes healthful living and prevention, and controls the growth in health care costs, not simply one that fits the fantasies of free market ideologues.  

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