Richard Warren Field - Writer/Musician
An Overlooked Answer to Our Healthcare Dilemma
Co-written with Dr. Alan Fluger, DC
Posted on October 11, 2009
Copyright © 2009 by Richard Warren Field and Dr. Alan Fluger, DC
The United States health care system, as it functions today, reflects two pervasive American attributes: a love of technological innovation, and a take-charge attitude toward problem-solving. These two attributes have certainly led to triumphs in health care, to longer and more comfortable lives. But they have also led to the problems that have made “health care reform” such a hot topic. And a major problem deriving from this, and driving the call for reform, is expense. Expense can be directly traced to an overemphasis on the priorities set by the love of technology, and a problem-solving approach to health care.
Technology has led to life-saving and life-prolonging innovations in medicine. Cancer is no longer a death sentence. Heart attacks are also no longer always fatal, and patients with unhealthy hearts have options that were unavailable half a century ago. But these triumphs of technology have led to a technology-first mentality. The first steps taken by the mainstream medical community usually involve drugs, and for more serious conditions, some sort of surgical intervention. In short, the bias is often toward the most intrusive care, a bias formed partially by a pride of living in a technologically sophisticated world.
Related to this is the take-charge, problem-solving attitude toward health care. Conventionally trained medical doctors look at lists of symptoms, come up with a diagnosis, then attack the problem with a cure: drugs, surgery, therapy—whatever the practitioner decides will eliminate the problem. Any good conventional practitioner is well-versed in the most modern solution to these problems—the latest drug, the latest surgical procedure. And patients expect to get the most modern “cure” available. This problem-solving approach to medicine, coupled with the love of technology leads to a misordering of priorities for health care, driving up expense, and creating clinical approaches not always in the best interests of the patient.
Love of technology and an attack-the-problem approach to medicine have led to a bias favoring more intrusive care over less intrusive care, and toward “sick-care” over “well-care,” designed to prevent the illnesses in the first place. An example of this is the treatment of neck and back injuries. The conventional medical doctor is likely to prescribe muscle relaxers, anti-inflammatories and pain medications to address the symptoms of discomfort. A neck brace could be included in this initial treatment. If symptoms don’t subside, more drugs are prescribed, along with physical therapy. If that doesn’t help, the patient is referred for an MRI. If the MRI shows a bulging disc, surgery is contemplated. So the very first care involves introducing chemicals that have their own side effects. These chemicals also can mask symptoms, so the patient fails to take measures in behavior to facilitate the body’s own healing processes. Physical therapy is certainly a less intrusive mode of care, but physical therapy is not the most effective way to correct the spine for healing. And surgical answers to bulging discs can often lead inexorably toward more follow-up surgeries. The fusion of some vertebrae, a common surgical approach to bulging discs, distorts the surrounding vertebrae, leading to more back surgeries. This can also distort the patient’s gait, leading down the line to hip and knee replacements.
Like most medical conditions, back injuries would be treated more efficiently and effectively by starting with the least intrusive care. If a vertebra is out of place, often the source of the discomfort, then a chiropractic adjustment can be used to put the vertebra back into place. Adjusting the spine to effect healing is a time-tested healing method. Massage can help the discomfort during the healing process, instead of chemicals. Even bulging discs can be treated with less intrusive care. Inversion therapy can be used to tilt the patient to use gravity and the body’s natural healing processes to decompress the nucleus propulsus, which is a lot like jelly, getting it to retract back into its spaces.
Another issue to consider in addressing back injury treatment is to consider the effects of maintaining a healthy spine with regular spinal well-care. An optimally aligned spine is less prone to injury, sustaining less severe consequences when subjected to trauma.
This example of dealing with a back injury can be extrapolated to apply to many health issues. The focus needs to be on maintaining health, instead of addressing health only when illness occurs, and in the event of illness, start with the least intrusive care first, progressing toward more aggressive care only if the less intrusive care proves to be ineffective, and the side effects and consequences of the more radical care are acceptable when weighed against the current circumstances. This is not a call to abandon conventional medicine. It is a call to set priorities more effectively, to save costs, and to emphasize ongoing health maintenance as opposed to being concerned about health only when the patient is not healthy.
What segment of the heath care industry is in the best position to reorder these priorities? Chiropractors are. Chiropractors emphasize wellness over sickness. They are trained to position the body, through adjustment of the spine, to heal itself. And if we think about it, that is what a lot of conventional medicine does. The orthopedist sets the fractured bone and immobilizes it so the body can heal it. That big gash is stitched up by the emergency room doctor so the tissues can grow together. When doctors say to rest and drink plenty of fluids to address that cold, they are also positioning the body to heal itself. And healing through natural body processes is preferable, because it comes with no side effects.
Chiropractors can also work with patients undergoing more intrusive care to help position the body for healing. We would never suggest that intrusive care should not be used for a malignant cancer. But while chemotherapy is taking place, a hard process for the body to absorb, the patient can maintain a healthy spine, and concentrate on well-care for the other body systems, to absorb the effects of chemotherapy as unobtrusively as possible. Even that broken bone patient, waiting for the bone to set, can benefit from a wellness approach to facilitate healing, by making sure the spine is aligned, and all other systems are as healthy as possible.
This argument for chiropractors as primary health-care givers will jar many people reading this (those not familiar with chiropractic). Those steeped in the conventional system will say a more logical approach would be to retrain general practitioners, or use nurse practitioners (there have even been suggestions to use pharmacists), to deal with the well-care and less-intrusive care. But coming from the conventional medicine background, these parties simply wouldn’t be the most effective implementers of this idea. Chiropractors are trained in well-care, in less intrusive care, in natural, homeopathic remedies. Their professional culture is infused with this mindset—the medical doctor professionals would need to adjust their thinking.
But most important of all, chiropractors are practitioners of spinal manipulation. They focus on maintaining a healthy central nervous system with non-intrusive manipulation of the vertebrae to make sure those vertebrae are properly aligned. They recognize the importance of the spine to the entire body. We have a “central nervous system,” aptly named, as it dominates the center of the body, branching out into every extremity. Evidence is abundant connecting individual vertebrae to areas of the body. Misalignment of the lumbar spine can cause constipation, bladder problems, menstrual troubles, sciatica and backaches. Misalignment of the cervical spine can cause headaches, dizziness, sinus troubles, neck pain, eye and ear troubles, and allergies. Part of any well-care plan would be to maintain a healthy spine. Retrained general practitioners and nurse practitioners are not the best to do that. Chiropractors are. Legions of them stand ready to step into the system to create a healthier population, and save expense in the process.
Those who are not familiar with chiropractors will likely revert to some stereotypical ideas. They perceive chiropractors as “back-crackers,” and deride the ideas behind chiropractic as “quackery.” And a limited look at the history of chiropractic reveals it as a recent American innovation from the late Nineteenth Century. Chiropractic started in the American heartland, unfortunately for its reputation, about the same time as snake-oil and patent medicine salesmen were plying their “miracle cures” all over the country. Because of this origin, and the efforts of the established medical profession, chiropractic has in the past been tarred with this “quackery” label.
But while chiropractic is a recent American development, spinal manipulation has been around since recorded history. Hippocrates, the man whose oath medical doctors take, an oath almost 2500 years old, was a serious practitioner of spinal manipulation to heal people. Hippocrates wrote “Look well to the spine for the cause of disease.” He looked for and recognized different degrees of vertebral displacement as something that needed to be corrected. And he referred to this as an “ancient art!” Around the same time, a slightly older man than Hippocrates, the historian Herodotus, apparently was doing some kind of spinal healing, because there is a record of Aristotle criticizing this practice a few generations later because Herodotus’s methods “made old men young,” prolonging their lives too long. Spinal manipulation as a method of maintaining a healthy body has been around for thousands of years, in cultures all over the globe.
So while chiropractic is a more recent American health approach, it is simply the method of spinal manipulation combined with modern medical knowledge, with knowledge unknown to Hippocrates or Herodotus, or to spinal manipulation practitioners through the centuries. Chiropractors are highly trained in cutting edge information on the human body and healing techniques. Like medical doctors, they go to school to learn chiropractic techniques, for a minimum six year program. The snake-oil people from a hundred years ago are gone. Their scams were long ago exposed. Chiropractic is still here because it is effective, and because it has roots that go deep into antiquity, as far back as any modern medical technology goes back. Chiropractic combines the ancient knowledge of spinal manipulation with all the medical knowledge of our Twenty-First Century world. Chiropractors are ideal partners for medical doctors as we shift toward less intrusive measures first, and a stronger focus on well-care.
How should this shift be achieved? Should the government take over the health care system and order everyone to see chiropractors first, before medical doctors, then set the prices of these visits to control costs? We stand with the many concerned citizens who utterly reject the idea that the government can effectively run health care. Government’s answer to controlling costs will be to slash fees. They will drive doctors (chiropractors and MDs) and other health care professionals and entities out of the business. This will create shortages, which will lead to some form of rationing. This sequence of events has already taken place in other countries that have government-run health care. If you speak to Canadians who are healthy, they are likely to laud their system, because they pay nothing for insurance. But if you speak to Canadians who are sick, they will likely lament the long waits for care. And if you speak to Canadians with life-threatening illnesses, with a desperate need for immediate care, they will be talking about the feasibility of coming to the United States for care because the long waits in their own country could be fatal. Government will not solve this problem by taking it over.
But government does indeed need to consider “reforms,” because some of the government’s current policies actually harm the system and lead to some of the distortions that have created the mess we have now. To understand this, we will offer a brief historical perspective on how we got where we are, and what fixes could be implemented to mend the system. Most Americans get their health care through health care insurance provided by their employers. This occurred because during World War II, the government froze wages. But this was still the United States, where free enterprise is deeply engrained. Labor was scarce—millions of Americans were employed by the United States military. To attract the best and brightest, employers had to offer incentives other than salary. Maybe they could have offered food, or housing, or clothing. But they offered free health insurance. This has led to the unfortunate and confusing interchangeable use of the terms “health care,” and “health care insurance.” As a practical matter, over time, those terms became equivalent. Employers bought insurance plans that paid for almost everything. Employees spoke of their “great health insurance,” great because it paid for everything. This shot up the price of health insurance (along with the increasing costs of health care, for a variety of reasons). HMOs were created to offer this free or nearly free care to employers for their employees as a way to control the rising costs. Government regulated health insurance policy coverages because of the reality that most employees knew little about the details of what their employers had bought on their behalf, what coverages were included. Employers don’t pay for food, housing or clothing. Employees pay for these essentials of life out of their salaries. But employees have grown accustomed to someone else paying for health care.
In Crisis of Abundance (page 46) author Arnold Kling describes what he calls a “set of three principles that ‘must’ be satisfied by a perfect health care system.” People want to be able to get care when they need it, they want to be able to get quality care, and they want to be insulated from the costs. But as Kling points out, these three “principles” are not compatible. At least one of these principles needs to be minimized as a priority. In government run care, it can be argued that two of these principles are sacrificed, quality and availability, with the priority on insulation from the costs. In a free enterprise system, the correct choice is to drop the third principle, insulation from the costs. This does not mean we would favor dropping all insulation from the costs. People should be insulated from catastrophic costs. This idea would mean having insurance companies return to providing insurance instead of engaging in the bureaucratic administration of health plans with convoluted rules that make the government look simple by comparison. And with this change, the free market would return to the health care system, and market forces could work to undo some of the inefficiencies and waste present in the current health care system.
At first glance, this idea will seem extremely unattractive. But compared to giving up the other two options, this is the one we should prefer to abandon. And the blow of jettisoning this option can be softened by getting employers out of the business of choosing our insurance for us. Instead, have them offer our medical benefits in the form of pre-tax health care spending dollars to employees to use in the market place for insurance coverage, to pay directly for care, or a combination of the two. Government should give incentives to employers to offer this benefit. After the health care spending account dollars are spent, the employee would need to use his or her own resources (as we do to pay for food, shelter and clothing) to pay for additional health care or insurance coverage.
Coupled with this would be a deregulation of the insurance industry. Insurance companies would still be held to claims handling standards, and requirements to maintain solvency to pay claims with premium dollars. But health insurance companies would be allowed to offer health insurance policies to employees in all fifty states, with many varied innovative coverage options available. We would expect one of those packages to involve chiropractors as the primary caregivers, with coverage for less intrusive care first, for more intrusive care only if it becomes necessary. We suggest that this might be one of the most economic coverage options available, because the focus on well-care, and less intrusive care would be less expensive than the current conventional health care approach. With public education, through essays like this (and through other writing like our novel, Dying to Heal), through classroom materials in high school health classes, we are confident many would choose this type of policy, given the freedom to do so.
In fact, the logical coverage option for most people, with lowest price tag, would be coverage for catastrophic care, with insureds paying smaller expenses directly from health care spending accounts and/or their own pockets. Such a policy would provide coverage that caps at a set amount for care during a given year, at a number the insured would choose, depending on the insured’s individual circumstances. The cap could be $2000, up to $20,000 (or even more), with the premium much lower for the higher cap. The chiropractic care policy would pay for well-care visits, with the idea that paying for those visits will reduce the likelihood of more serious illnesses down the line. But coverages would be designed to suit the needs of the individual insured, giving them the choices on what options suit their circumstances the best.
Other important regulatory adjustments would also need to be made. Insurance companies should not be required to offer coverages in their policies that their insureds do not want. With the employer choosing insurance coverages, there was a need for government to make sure certain coverages were offered in the policies because consumers were so far removed from the coverage decisions. But with people choosing their own policies, more variety of coverages needs to be allowed so insureds will not be required to pay for coverages they will never use. Coverage for abortions makes no sense for the policy-holder who is not going to have an abortion, maybe on religious grounds, or because she had a hysterectomy, or because the insured is a single male. Counseling, and other frills, should also be options, not coverages mandated by government, with the result of driving the price of the coverage up. A no-frills catastrophic health insurance policy that pays all annual medical expenses for a family over the amount of $5000 would likely be much less expensive than the policies offered now. Health insurance might just become affordable again.
With this change, the insurance policy would now be owned by the individual employee, not the employer. When employees change employers, they would take their coverage with them. A new employer, with another health care spending account, would give the new employee the means to continue that coverage. The whole element of people losing health care coverage when leaving an employer would be eliminated from the system.
Three other issues related to these ideas need to be addressed. First, those with pre-existing conditions and no current coverage need the capability of getting health insurance if they want it. An assigned risk pool could be established, as it is utilized by the auto insurance industry. If insureds cannot get an affordable health care insurance policy on the open market, they would be placed in a pool and assigned to a company for a catastrophic health care policy with a cap like the one we discussed earlier. Companies would take these assigned risks based on the share of the health insurance market they have.
Also, insurance companies should be allowed to discount risks based on specified health criteria, like a healthy weight, healthy cardiovascular performance for the insured’s age, and healthy blood sugar, blood pressure and cholesterol levels. Healthier people pay lower life insurance premiums. Better drivers pay lower car insurance premiums. Those who maintain their health should pay lower health insurance premiums. Insureds would have a monetary incentive to look after their health, to collaborate with their chiropractors (or other primary health care professionals) to maintain health and prevent illness. This is another way the free market can enter the health care picture.
With patients now holding the purse strings, of their health care spending accounts, or their own resources if the funds in those accounts are exhausted, questions will be asked about whether tests, prescriptions and procedures are necessary. Providers who charge exorbitant amounts may find they need to lower prices or lose patients. One issue will arise immediately. Doctors who order tests and procedures, and prescribe medications “defensively,” to give themselves a defense in the event of a possible future lawsuit, will find themselves questioned as to whether the test, procedure or prescription is really necessary. Doctors will worry that if the patients refuse the test, prescription or procedure, and a future adverse result occurs, they will be facing a trial lawyer accusing the doctor of negligence. Tort reform should be considered an important part of reforming the health care system in the United States. True malpractice needs to have remedies for compensation. But lawsuits perpetrated to try to hit the litigation lottery need to be discouraged. There is a balance to strike, but beyond this recognition of the issue, we will not go further into it here. If tort reform cannot be a part of these reforms, doctors may need to get signed waivers from patients who refuse the defensive test or other care, to protect the doctor from a future frivolous lawsuit. Solid tort reform would hopefully eventually render such waivers unnecessary.
So in this essay, we are advocating a health care system that emphasizes wellness over illness, and less intrusive care before more intrusive care. Chiropractors are the logical heath care practitioners to make this work. This system would operate outside of direct government control, with free market incentives brought back to the health care and health care insurance industries by utilizing health care spending accounts instead of employer purchased health insurance, and by ending regulations that only allow insurance companies to sell in one state at a time, and that require coverages that an insured might not need to be offered on a policy. The United States culture and ethic has stimulated great innovation and progress in many areas of human life, including health care. We offer these ideas, in that spirit, as another innovation to benefit people within a free, prosperous society.
Dr. Alan Fluger, DC and Richard Warren Field are the authors of Dying to Heal, a novel about the health care system that dramatizes the issues raised in this essay.
Richard Warren Field is the author of the award-winning novel, The Swords of Faith.
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