Blood Sport: Do-or-Die Time

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As we have been writing it, media attention has suddenly preoccupied itself with the sorry state of the American health-care finance and delivery. The furor reached a new level of consequence on September 8, as Federal Reserve Chairman Alan Greenspan digressed from his near-term economic analysis for the House Budget Committee to hold prophetic court on the decades ahead: “As a nation, we may have already made promises to coming generations of retirees that we will be unable to fulfill.? The reality of health care in America is that we don't have the dollars to foot the bill for today's needs, nor tomorrow's escalating costs.

The current government obligation for taxpayer-funded Social Security and Medicare is said to total more than 10 times the $4.2 trillion national debt. What's more, we know that with age, health-care expenditures increase. As new technologies and pharmaceuticals intervene to keep Americans alive longer, even as they suffer from chronic or acute disease, post-symptomatic life expectancy could grow by leaps and bounds. An irony of living longer, however, is that the price is steep and certain to soar, especially during the last two years of life. America's health-care complex can barely tolerate today's level of demand, let alone serve an exponentially growing patient population.

An analysis of the financial and political options for health-care management and reform today, in light of an almost certain meltdown in the nation's capacity to keep a rapidly aging populace healthy, might well promote a deep sense of unease in every citizen, but especially those of us over age 50. The reality of American health care is that it is woefully unequipped with lifeboats for all.

Let's look at the math for a moment:

  • 59 million are over age 55, when people begin to show health disorders.
  • 38 million people are ages 45 to 55
  • 23 million more are ages 40 to 45
  • Fast forward to 2020, apply current death rates, and you get a grand total of 110 million people over age 55. Likely, they'll compete among one another for vital health resources.

Moreover, we need to consider the rapid run-up in life span. Nothing like this has ever occurred in human history:

  • 35 million Americans today are over 65, receiving Medicare.
  • 4.6 million Americans are over 85, consuming health resources at the rate of more than $16,000 per person per year. 1 By 2020, Americans in the over-85 category will at least double, maybe triple, or even get worse as life-prolonging technology advances.
  • The typical aging person, suffering a slow death from a chronic disease, burns roughly $150,000 in the last 6 months of life.

According to Lincolnshire, Ill.-based global human resources consultancy Hewitt Associates, 2 in 2004, health insurance costs will exceed $7,000 per employee, and this figure continues to rise at a double-digit rate. The heaviest part of this load is being borne by Boomers, but today's over-85 cohort " many of them Boomers' parents " are consuming more than $16,000 in health care, per capita. Current health-care expenditures for a 65-year-old are now four times those for a 40-year-old. U.S. health-care expenditures are projected to increase 25 percent by 2030, because the population will be older and greater in number. 3 We're almost certain that expenditures for Social Security, fixed and variable pensions and disability payments will burst their respective cupboards in the mid-2020s.

In any case, we'd estimate that total 2025 expenditures for the caring and feeding of America's aging populations will be roughly $5 trillion per year when the youngest Baby Boomer turns 65. To service that population, roughly 20 percent of the U.S. workforce will be dedicated to taking care of old people. In a recent forum on the nation's health-care crisis, president of the Hospice of Michigan, Dottie Deremo, cautioned, “Baby Boomers will be like velociraptors eating every health-care dollar in sight.? 4 Yikes!

Blood Sport: Access to Care

Nothing in the world quite matches the American health-care complex 5 . It is one of seven trillion-dollar industries in the U.S. It can save a blue baby from Rwanda, and deny treatment to an uninsured middle-class baby in Chicago. It can provide the most sophisticated health care available to both an affluent person and an indigent person. Too often, though, it leaves masses of people between the two extremes in a state of arrested risk.

Many believe that insurance and Medicare will provide protection against health liabilities. But, given the supply squeeze, costs are disproportionately rising. In any case, we'd bet that minimum co-pays will continue to rise significantly (as they have this year), service cuts will be inevitable and age limits will creep up as the system becomes loaded with 110 million eligible citizens 65 and over.

At the same time, preventive health is practically nonexistent in our disease-centric medical delivery complex. 6 (While the U.S. spends more on health care than any other industrial nation " 13.1 percent of gross domestic product " it ranked as only the No. 37 healthiest nation, according to World Health Organization data.) Traditional annual exams leave much to be desired. Tests are restricted; practitioner time is limited. From an economic perspective, the fact is that it is not a good investment for an insurance company to spend on a bone scan today to prevent a hip fracture in 30 years. By then, a broken hip will be Medicare's problem. Insurance is a transactional business " cash reserves in the present inevitably trump certain risk in the future.

Relatively few people work for a company that offers lifelong health benefits. These companies are under extreme pressure to reduce benefit costs. 7 As a result, post-retirement benefits are being cut or eliminated. Second, those companies that offer post-retirement benefit liabilities are moving the age line of qualification.

But the big bulge factor is the moving of the modal age in America. Today, 1 in 5 in a population just shy of 300 million is over the age of 55. Over 1 million people are over the age of 90, and by 2050, 5 million people or more will likely eclipse age 100. Who knows how long Boomers " birth years 1946 to 1964 " and the “greatest Generation? " those born between 1927 and 1944 " will last?

An already growing litany of strains puts the care of the greatest Generation at risk. First, we have fewer children compared with our grandparents, averaging less than two per nuclear family. Hence, fewer available caregivers. That grown children are less likely to live in the same town as their parents, due to jobs, relationships, etc. compounds the shortage of familial caregivers. High divorce rates, and the resulting disruption of the family of origin, further intensify the challenge of caring for America's seniors. All told, a weakened sense of kinship and community will exacerbate the pressures on the American health-care complex as social safety nets fail. These issues will only become more problematic over the next couple of decades as Boomers age.

Baby Boomers began turning 50 in 1996, 60 in 2006, and they begin turning 70 in 2016. Never has a generation entered its mature years as strong, as beautiful, as healthy and as aggressive at defending personal interests as the Baby Boom. With what is at stake, they will not go quietly into the sunset of their lives. Trouble lurks on the social horizon.

The magnitude of the problem does not end with demographics. Medical technology and science are heavily invested in extension of life therapies. Personalized gene therapies may provide you the opportunity to purchase (no insurance here!) replacement parts made from your own DNA, grown in a lab for insertion into diseased tissue. The conventional health-care community is beginning to explore and research a broad range of Complementary & Alternative Medicine 8 (CAM) therapies. These therapies are widely available in America for wellness and health maintenance as well as disease management. Molecular science businesses are distilling life-energizing proteins and related complex molecules from food sources, putting therapeutic review outside the scope of the Food and Drug Administration (FDA). If you can afford them, clinical services, nutritional intelligence, naturopathic remedies, physical fitness and attention to your personal spiritual needs may give you the added potential to maintain and sustain physical and mental health well into your 100s.

Situational Vector

The situation is frighteningly simple: More people will demand more services from a shrinking complex. Some will be in a position to benefit; others will not. The complex will disallow service through queuing strategies, triage strategies, denial of service strategies, delayed entrance strategies. The complex will do whatever it takes to reduce the patient load to that which the system can sustain. We fear that a rising provider bias for cash and a seemingly random access model for everyone else will squeeze the kindness out of American health care.

Triage by inability to pay has already begun. The 20th century expectation that “health care is a right, not a privilege? has already been hard hit, given the sheer numbers of uninsured Americans. Forty-four million working Americans have been excluded, either because of poverty or the inability to acquire insurance from their employer. At the same time, denial of service by insurance companies is growing for health services that range from diagnostic tests to life-extending interventions for patients with cancer. health care becomes a blood sport: to the victor goes a long life.

The current health complex is set up to respond to effective clinical and wellness service demand by knowledgeable individual patient-clients. People who early on arm themselves with knowledge against the obstacles and inefficiencies of the system will be well served by America's superb resources.

Interestingly, advantage redounds to those who fall seriously ill at a relatively young age, or who have a loved one who has to deal with current disaggregated health-care delivery. They are better informed because of their exposure to the inconsistencies and gaps in the present complex. However an individual can wise up to the complex, it is essential. There are not enough health resources to go around today. And, because there is little or no chance there will be a sufficiency of resources when you are in your 70s, most individuals will suffer if they fail to build adequate personal health management practices at the time they were in the best position to do so " i.e. NOW!

Denial Ain't a River in Egypt

Forewarned, as the coming health implosion unfolds over the next two decades, is forearmed. There are three trends simultaneously threatening the viability of the American health-care complex.

We are all aware of the first trend: aging healthy or healthy aging. Life expectancy hit just under 77 in 2000, but more interestingly, the rate of increase in life expectancy over the prior 10 years averaged a month in life for every year lived. By this calculus, we should have been on track to hit 80 around 2020. But recently, statistics show a sudden surge. Life expectancy rose 3 months in 2001, with women crossing the 80-year mark in 2002. Also, the gap between men and women is narrowing. The guys are only a year or two behind the gals.

As the Canadian government " a group that does behave like a system " has noted in a Ministerial report issued in 2000,9 the process of life extension is likely to continue to accelerate. Technologies, surgical procedures, dialysis procedures, pharmacogenomics, heart disease innovations, new pharmaceuticals and genetically-specific drug design have already begun to play significant roles in symptomatic disease management.

These dramatic technologies are coupled with a rising willingness on the part of consumers to utilize age-extending personally managed therapies, such as fitness training and holistic healing therapies (including some outside mainstream medicine practices). Also, there are drug-light hormonal and complex proteins sold over the counter as nutritional supplements. For example, Kemin Food's effective Lutein product is a macular degenerative disorder management molecule, and it is found in many vitamin products.

Doctors' Ranks Decline

The second trend is a little more obscure: Doctors are retiring. The table below was drawn from a recent report of the American Medical Association (AMA) and offers sobering insight into a classic evolving demand-supply squeeze.

The table 10 examines the top 10 Board Certified health professions in the U.S. For the record, these physicians represent little more than half of the 854,000 doctors currently practicing in the nation. In short, we have a declining level of service providers and a growing number in need of those specialists. Ouch. We are looking at a supply squeeze that is immune to either policy or an increase in product.

The American Academy of Medical Colleges reports that roughly 18,000 new medical students (both U.S. and foreign medical colleges) annually enter professional schools. 11 Assuming no drop-outs, approximately 270,000 new doctors will be in place by 2020. But, as 425,000 MDs retire (or partially retire) and demand doubles, we are in for some trouble in the health-care supply side economics.

What kind of trouble? If Adam Smith is correct, and supply-demand disequilibrium results in compensating cost changes, the supply shortfall could add as much as 33 percent to the cost burden. In simple terms, this would mean an added cost burden in 2020 equal to the entire Medicare budget today (on top of an estimated 58 percent increase from structural demand issues).

Blind Justice

The third, even more insidious trend is the one toward imaginary solutions. These are embedded in the political thinking of both the Kerry and the Bush campaigns. The long and short of it: The ideas of both candidates are based on the presumption that health care is an entitlement open to all on a fair or just basis.

Fairness is the current standard by which life-extending therapies are to be distributed, with the presumption that sufficient supply exists for most therapeutic requirements. But this is already not the case. (And, too, fairness only became the standard in the last 50 years. Historically, health care has been inequitably distributed by income: Wellness was a luxury of the rich.) For example, there is a shortage of replacement organs such as hearts, lungs, kidneys, livers, etc. The fairness remedy is queuing. In the case of organ transplant material, fairness is managed by a system in which each recipient waits in line for a genetically sympathetic organ without respect to class or means. If the material fails to arrive by the moment of terminal denouement, you die. If it arrives in time, you live.

We estimate that by 2020 (based upon a simple doubling of the size of the relevant age group) that demand for coronary artery bypass heart surgeries will increase to over 1,200,000 per year, from the present volume of about 600,000. 12 Assuming that the 50 percent retirement rate applies to coronary specialists, and the same replacement rate applies as for other specialties, we forecast a 30 percent decline in available heart surgeons by 2020. Even if we allow for big improvements in productivity, robotics, surgery and better prevention of coronary disease, 400,000 people will still not be able to get the procedure. The same will occur for people requiring cancer treatments, dialysis, intervention for neurological disorders and the like. If the procedures are unavailable through lack of supply, people who would otherwise live long “post-symptomatic? lives will perish.

The question is how fairness will be adjudicated. In the United Kingdom and Canada, fairness is managed by the creation of age-based triage rules and random queuing management. In the U.K., if you are over age 65, you are at the bottom of the list, as long as a younger patient remains in the queue. Should a procedure become available, you receive it in the order of your diagnosis date, with some forgiveness for criticality. In Canada, except for emergency trauma, it is all queue-based. The result: Canadians come stateside for self-paid procedures.

One Canadian reported that her sister underwent an MRI for possible multiple sclerosis in November of last year, but no one was available to interpret the results for nine months, during which the disease advanced. Under Canadian rules, she was queued until a specialist became available. In Britain, a woman reported that her husband finally made the list for a knee reconstruction last year, three years after he had passed away. Apocryphal or not, these stories suggest that fairness will be rule-governed. Only the clever and those with the resources to buy their way into privatized health practices will be able to avoid a new game of lotto in which you literally bet your life. Nasty.

The Candidates' Debate

There is no political issue like health care. The president signs a drug bill and wakes up the next morning to realize he had underfunded the initial authorization by 100 percent. Democrats pledge uniform national health care as policy. And, Baby Boomers believe Medicare and, in some cases, medical insurance will protect them. They think of health care as a “paid-in entitlement.? It is that sense of entitlement expressed in thousands of voter focus groups that animates the staffs of both candidates.

Our two presidential rivals offer very different health-care proposals. The Kerry camp calls for a national insurance process, enabling health care to be available in quality to 95 percent of the American population. Still, insurance is a mutual income pool, depending on revenue flowing into the pool at least as fast as it flows out. Kerry is asking for an outflow of an additional half a billion dollars or so per year over the next 15 years. In Kerry's view, the inflow revenue will come from taxing the wealthy.

This is a naive opinion of the willingness of the wealthy to share, and a naive view of the American public's willingness to absorb substantially more taxation to pay for a generation that underfunded its health-care needs. First of all, adding 44 million uninsured people to the ranks of those who are already being carried by government programs " Medicaid/Medicare " will tank the complex, however noble an idea. Further, a fully funded program will run into the trillion to trillion-and-a-half dollar range by 2025. Under optimistic forecasts, funding the health needs of Boomers and their parents, amid a declining tax base as a result of large-scale retirement, would “stick? our children with FICA Medicare support payments of at least 30 percent of their income. This financial blow would strike a relatively smaller workforce.

Kerry and Edwards propose to protect access through a sort of health-care bill of rights, making denial of service a tort " that is to say a malpractice. We assert that denial of service is inevitable. The only practical system for managing demand flow in single-hospital cities is the queuing model (and with it complex queuing interventions by those who can jump the queue through chicanery, the ability to pay, or most likely, both). We cannot sue our way to equity in health care. A rash of lawsuits will force quality medicine underground into the already growing business of private clinic surgical centers, boutique medical practices and medical spas for those that can afford them. Whatever the merits of the bill of rights system, the Kerry program does not address the key issue: supply.

The Bush proposals are a little more realistic on the need to build service-payment oriented liquidity, but likewise do nothing to address supply-side health economics. Bush would make health-care income set asides with pretax dollars available to all families in America. This could make it easier for middle-class families to play “jump the queue,? but it does not solve the problem of the size of the queue. At the same time, Bush would establish support for community health centers to relieve some of the pressures on regional hospitals. But, new centers will likely drain staff from existing facilities, putting them under a federally induced cash-flow strain. In short, the problem is not the absence of a desire for goodwill and fairness in health-care service distribution, the problem is that lack of supply makes this is impossible under any currently conceivable scenario.

Interim Considerations

Partial fixes may offer a modicum of protection and short-term solutions. For example, a broader utilization of medical professionals such as nurse practitioners and physician assistants as physician “extenders? will help. 13 These clinicians are capable of managing patients independently, in teams with other clinicians and/or with doctor oversight. Licensing and independent practices vary from state to state, and consumers, who are used to seeing ‘The Doctor? may protest. Extender precedents exist in specialized care, such as for diabetics, who are frequently monitored by a “team? including nurses, educators and nutritionists. At university health centers, students are often screened and treated by a nurse practitioner or PA only. Pregnant women typically see nurse midwives at prenatal care visits, and even for the delivery in some cases.

The reality, however, is that American health care is broken, and perhaps impossible to reconfigure for now, in part due to fragmentation and lack of incentives for current stakeholders. There is no one poised to create or train teams or set up viable networks. And, if this route is taken, it will be an agonizingly slow process. Doctors are not trained to work in teams, they like autonomy. Paraprofessionals may run into difficulty without adequate malpractice insurance coverage. Educating twice the number of docs will take a while; there just aren't enough medical school dollars, professors nor the ability to reorganize to ensure rapid ramp up of doctors that quickly.

Plus, the need to increase the numbers of graduating doctors would not only have an impact on medical schools, but also on residency training and supervision. The structure of medical school classes, and on the wards of hospitals would not lend itself to the short-term nor even medium-term doubling in class size. All these reasons do not even take into account the need for an influx of funds, the tax dollars to support such changes, and the willingness of medical school administrations and faculty to adopt a logarithmic increase in class size. Since a miraculous cure to fix the ills of American health care is unlikely to happen quickly, to help you stay healthy to a ripe old age, what are your options?

Strategies Get Personal

In this blood sport, the wealthy, the informed and the motivated players will be the victors who will outlive the losers. Winners will be the ones who anticipate that access and preventive measures will extend their life and improve the chance of support from the unrelieved ugliness of an overburdened system. While many health problems arise based upon genetics, lifestyle choices, such as smoking, overeating, physical inactivity, are estimated to contribute over 50 percent of an individual's health destiny. 14 In a recent government study reported in the Journal of the American Medical Association (JAMA), researchers analyzed data from 2000 for the leading causes of mortality and for those preventable factors known to contribute to them. 15 Tobacco, obesity and inactivity increase the risks for the top three killers: heart disease, cancer and cerebrovascular disease, including strokes. Obesity and inactivity also strongly increase diabetes risk, the sixth leading cause of death. An editorial accompanying the study in JAMA says national leadership and policy changes are needed to help curb preventable causes of death.

Changes don't happen quickly. If you invest your time and attention in preparing for the inevitable risks of aging and participate in managing those risks, you will reduce your exposure to an overwhelmed health system and, in your own way, reduce the burden on that system. Plus, given all the emerging technologies, you will ensure a quality of life that has never been available to aging people before " just like the childhood you had, that no one ever had before.

A good defense is the best offense. To survive well you need to plan to stay healthy. There are FIVE keys to achieve this goal, and they depend on you:

FIRST, you must develop a close relationship with an internist, and in some cases, a family practice physician, who will see to it that you achieve a preferred position in the access queue. Internists have the keys to the health- care kingdom. The doors open to their recommendations because of their training, access privileges and the risk of saying no. The key is to use your internist for annual physicals that allow you to be a valued patient for the internist's practice as you build a deepening relationship. This will help your physician to gain insight about your body, mind and preferences for customized interventions throughout your life.

SECOND, choose to be an active participant in health-care decisions. This will involve coordination of input from a variety of trusted practitioners and may include CAM 16 “advisors? selectively; to determine interventions that minimize risk and maximize health benefit options as symptoms and/or diseases surface.

THIRD, consolidate your health records. Right now, they are spread among a records management system that is disaggregated and non-interoperable. Records are often inaccessible (especially if you have moved over the years) and subject to great delays in the delivery of health information of great importance to you when you become symptomatic (and, believe us, you will).

FOURTH, build a program of mental and physical wellness. Whether you manage it or you employ a nonconventional health advocate, the program should include fitness, stress reduction modalities, appropriate nutrition and, perhaps particular foods (e.g., such as omega 3 fish oils for heart protection) or vitamin supplements (such as folate) or other supplements (such as glucosamine for joint health). And, your program should be customized to fit you, with reference to your health profile, and attention to the messages your body sends for help. In addition, the benefits of contemporary technologies, including surgeries, for managing the physical stress of aging or minimizing the impact of specific diseases, such as joint replacement or cancer therapies, should not be overlooked. At the same time, strive to challenge your mind intellectually and maintain your appearance, in ways that gratify you, make you feel good and happy throughout life. Attitude counts. You will choose the cosmetics, the skin care, weight control programs, the exposure to the sun and the whole range of hobbies, intellectual pursuits, activities, and fitness therapies that are available with or without medical intervention.

FIFTH, engage your spiritual faculties. Whatever belief system you practice, it becomes more and more relevant as the years of ambition are displaced by years of wisdom and contemplation. The objective of the game is happiness and wellness. Without the capacity for reflection neither of these are easily available.

Strategies together are life-extending processes, but they may not be easy to accomplish without an open wallet. You will want to find a private health team. Of course, you may have had to deal with a serious condition, or alternatively, may be fortunate enough to have found a team in your health-care network already.

You will want to collect your records and create a records management system for future accessibility for you and your clinicians, and maybe your loved ones. You will employ professionals and, most probably, directly compensate them to assure access when symptoms strike. You will take full advantage of your resources. Upon reflection, the morality of our situation may disturb you, but your desire to maximize the quality and length of your life " and of your loved ones " will likely eclipse your sense of fair play. You will not lose this game because your victory will come at someone else's cost.

We asked people in focus groups, “Would you trade the well-being of your loved ones or yourselves for a health-care system that was fair to all if it meant that there was a risk of being excluded?? Without exception, the hundred or so we interviewed said: “I will do whatever it takes to protect my family.? Ecce homo.

A Final Note

Future historiographers will note that as the Boomer bulge passed through time as the cultural “pig in a python,? it screwed up every institution in its way. When they were children, they got new schools and a whole fashion industry grew up to supply the party dresses and Mary-Janes. When they were in college, America built colleges. When they matured, we created the service economy and even the information economy to service their curiosity. And when they got old, they used the ballot box to manage their right to last as long as they could.

Camelot is not shining on the hill. At Camelot, it only rained at night. For Boomers, it's going to rain cats and dogs all day long for 30 years. The health complex cannot expand to accommodate them all. So you'd better buy an umbrella, build an ark or learn to swim with the winners. Wisdom and wealth are key to living longer, happier and healthier lives. How all this will be judged is unknown.

1; 2 Hewitt Associates; press release; October 11, 2004; 3, Healthy Aging: Preventing Disease and Improving Quality of Life Among Older Americans, At A Glance,2004

4 Ravenous Baby Boomers set to devour health-care dollars; Rick Haglund, Booth Newspaper, September 22, 2004; 5 We use the word “:complex? in lieu of the word “system? because system implies the existence of a self-correcting feedback mechanism; the complex under discussion consists of fiercely competing elements, each determined to protect its interests.; 6 Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century (2003), Institute of Medicine, The National Academy of Sciences, National Academy Press, Washington, DC. Crossing the Quality Chasm: a new health system for the 21st century. Committee on Quality health-care in America, Institute of Medicine, National Academy of Sciences, 2001. National Academy Press, Washington, D.C.; 7 The Benefit Trap, BusinessWeek; July, 19, 2004; 8 Complementary & Alternative Medicine, abbreviated as CAM, includes clinical and non-clinical interventions,, a multiplicity of therapeutic (acupuncture), health (rolfing), and wellness (massage, yoga) approaches, as well as complete systems of care, such as Ayurvedic Medicine, Traditional Chinese Medicine, which incorporates acupuncture, herbal therapies and more.

9 Understanding Canada's Health-Care Costs c.f. Google); Data for this table were derived from: 10 Physicians Statistics Summary: Review of the AMA'S Findings on Physician Characteristics and Distribution; Wendy Abdo & Michael P. Broxterman, Pinnacle Health Group, October 6, 2004; 11 American Academy of Medical Colleges, 2004

12 John Muir/Mt. Diablo Health System, Web Publication 2004

13 Is There a Doctor in the House? Perhaps not, as nurse practitioners take on many of the roles long played by physicians, Andrew Blackman, WSJ, October 11, 2004; 14 Julie Britt, SHRMOnLine, 5.27.04; 15 Ali H. Mokdad, PhD; et al, Actual Causes of Death in the United States, 2000, JAMA. 2004;291:1238-1245.

16 CAM is Complementary and Alternative Medicine

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