Health care bubble

Similar to stock market bubbles that burst when the valuations far exceed the intrinsic value, I see something similar happening with the entire health care industry and practice. Health care is a market itself and constitutes a large fraction of the overall economy. However, here I’m talking about the practice itself after subtracting out the financial aspects.

The valuation of modern health care services is the expectations we have for what it can do to extend our lives or improve our quality of life given degradations from diseases or other handicaps. Similar to stocks being over-valued in terms of what we expect future financial returns will be, health care itself can be over valued in terms of what we expect it will return in terms of our future health or well being. In either case, there will come a time when abruptly a large number of people withdraw their investment into the market, sending it into a downfall. The looming downfall of health care is the health care itself.

The current health care system, with all its promises and achievements, depends entirely on the population’s perception that the cost/benefit analysis is in each person’s favor. We expect that the health care system will offer us remedies for whatever ails us, and we have confidence that the remedies will work in our particular cases.

Since early childhood, I had a fascination with the health care system as a concept. I entered life at the final end of the old generation of medicine that emphasized the family doctor as a general practitioner that handled most situations without referring to a specialist. At that earlier age, the specialist was a last resort type of referral when the general practitioner exhausted all of his capabilities, and at the time there was a necessity that the general practitioner do as much as he could before referring to a specialist. The specialists were rare and very distant for most people.

An aspect of this earlier care was the personal relationship built between patient and doctor. There was the era of the house-calls where the doctor would visit a home when needed. I vaguely recall this happening still during my youth where a doctor visited someone who in today’s environment would be expected to be transported to some office in order to see the doctor. The relationship itself was such that the doctor would be invited to family dinners or other special occasions, and he would show up. While that was a neighborly type of interaction, it was primarily a part of practicing medicine. The patient would trust the doctor when the doctor needed that trust. Also, the doctor would know more about the whole patient, allowing him to recognize early on when something needs attention. Early intervention does not require as much specialized skill as later intervention. The intervention may simply to advise to change lifestyle to avoid something that appears to be making things worse.

That kind of early detection and intervention is missing from our current system. More accurately, I guess, is that the current system replaced the human relationship between doctor and patient with scheduled standardized checkups and lab tests for early detection, and so-called evidence-based but actually cookbook-type interventions from memorized advice (lose weight, get exercise), to prescribing a medication that is indicated in some schedule that the doctor can look up. The nature of the current relationship postpones the early detection until it become obvious in a once a year half-hour checkup. It also limits the range of advice a doctor may give: perhaps a more useful advice to losing weight and getting exercise would be to recommend a new club to join where people are healthier.

The modern doctor is incapable of offering the kind of advice or recommendation that the prior era’s doctors could provide. Despite recent decades of repeated recommendations for people to get more exercise and eat better, and every doctor’s visit being reminded of one’s BMI score, obesity rates continue to rise and even the onset of obesity-related illnesses does not change the behavior. The advice to exercise more and eat better is clearly ineffectual even though it is backed by extensive evidence.

What exactly does exercise mean? What exactly does eating better mean? The basic answer is that the combination should result to a healthier BMI score. Yet we see people continue with unhealthy weight despite eating quality meals and regular trips to gyms with calorie-burning calculators. I think an older-era doctor would recognize the problem as more fundamental, the patient needs to change something in their social life.

People are social animals. We eat socially. We exercise socially. We may go out to eat with friends where everyone orders roughly the same caloric load because that is what is on the menu. Being social comes with the desire to mirror the others at the table. Some at the table may have better BMIs and this can confirm that the meals themselves are consistent with good health. Of course, people may opt for lower calorie options, but often this is negated by eating more of it, or by indulging in other ways.

For some people, their weight problem may be addressed by getting them to enter into other social groups, groups that socialize in more meager eating environments, for instance.

I recall early on being obsessed with how much value I get for my money at a restaurant. For a certain price dinner, I would prefer the restaurant that would provide the larger serving, or the serving with calorically-rich extras. Later, I experienced a finer dining place where the per-plate prices were much higher than I normally expected and the serving size was very small, often served in an oversized plate to frame a small portion in the center. Even as a part of me revolted at the poor return for the investment, there was a part of me that felt relief. It was a pleasure to have offered a small portion, and having to make it last in company of my table companions. I cannot afford to eat out that way on a regular basis, but it has changed my home meals where I delight in getting my meal to fit in the middle of a small salad plate.

Besides perhaps for tapas places, it is hard to find affordable restaurants that will offer small portions as the normal menu item. Finding such places and having a social circle that prefers such places could help a lot.

A similar thing can be said about exercise. Over my life, the current time has many more people with gym memberships and regularly attending those gyms. Meanwhile, overall, the population was thinner when I was younger. Certainly, the gym experience does benefit many people with better toned bodies with good muscle mass and cardio-vascular health than merely being thin. On the other hand, there are many in gyms who may be better off living in older times merely being thin was the norm.

In recent decades, we as a society has elevated the authority of modern medicine as so superior to older medicine. We look back at older practices as naïve and primitive. This is not without justification. Compared to earlier eras, we have longer life expectancy, and we constantly hear of cures for conditions that would have killed people in the past. For example, many people in the past were doomed with heart disease without the option of bypass surgery or stents. A person needing heart care in the older era would not enjoy the benefits available today. What we may overlook is the fact that more people need such care today.

I think over the past century or so, there was a transformation of the expectation of health care. The older era was focused on wellness care, without being explicit about it. Instead the wellness focus was a consequence of a close doctor-patient relationship during the wellness periods of a person’s life. The doctor would be familiar with what wellness looks like in his patient and he would intervene immediately if he noticed wellness degrading. The intervention would have been offered out of friendship and concern: for example, suggesting a new club to join, or inviting the patient into a different social circle. This is not medicine in the modern sense, but it could be very effective in preventing the need for medicine in the modern sense.

In my imagination and recollection, the older medical model was more focused on the well-lived life. A doctor could retire happily with patients who appreciated his services despite the fact that he never had to do anything heroic or miraculous to save or improve their lives.

The modern doctor’s retirement aspirations, in contrast, is on list of accomplishments of fixing patients, or on a well-funded retirement. Socializing with patients is not a part of modern medicine. There are no house-calls. The modern doctor does not expect to be invited to family events and is not expected to accept any such invitation. To be fair, as a modern patient, I don’t expect a social relationship with my doctor even if the health insurance plan allowed me to keep my doctor year-to-year.

All of this is to say there is a comparison between old and new medicine. Closely considering the overall picture can at least suggest benefits of the older and failings of the newer. It is great that newer medicine can solve problems that would have been hopeless in the past. It may not be so great that these miracles are needed more frequently. I acknowledge the modern accomplishments of the overall statistics of longer lives and people having more vibrant lives later in life. I am not so sure that these are entirely the result of modern medicine. The modern world has many benefits that contribute to longer and healthier lives. It would be wrong to attribute everything to modern medicine.

Meanwhile, there are worrisome trends in medicine. As we boast of healthier and older old populations, there may be an increase in chronic illnesses in young people. The trend correlates in a suggestive manner to aggressive childhood vaccination schedules.

The modern miracle of vaccines to prevent certain diseases may come at a cost of injuring otherwise healthy people, many of whom faced no serious risk to the prevented disease. Until recently, the bulk of vaccines have targeted very young children and babies whose lives to that time are too short to have confidence in their innate health. When they later develop some chronic ailment, a credible excuse is that the ailment was a late onset of something that was going to happen any way.

We are entering an pandemic response that will mandate a new vaccine for the entire population, eventually. Everyone will be exposed to the non-zero risks of harm from the vaccine, and given the too-short testing period, we have no estimate of the long-term risks especially for younger people from childhood to early adulthood. Meanwhile, the vaccine targets a disease that has very little risk to the same young people.

The current policies are unstoppable at this time. Inevitably huge portions of the population will receive the vaccine. Maybe it will be perfectly safe. If it is not safe, there will eventually be observed with abnormal rates of certain conditions or injuries that we will not be able to ignore within a couple years time.

Vaccines have become one of the pillars of modern medicine. A fundamental social marker of trust in medicine and trust in science is the professed trust in vaccines, and the eagerness to take any offered vaccine. Any erosion in trust in vaccines will inevitably erode trust in modern medicine and modern science.

Vaccines have been around only recently in human history. There were periods in the past with devastating epidemics, but survivors managed to carry on and humanity advanced in numbers as well as in civilization. There were also long periods without major epidemics. It is possible for humanity to thrive on this planet without vaccines for naturally occurring pathogens, even if occasionally we have to suffer a substantial die-off. It is at least fair to compare outcomes of the era of vaccines with the era before vaccines. With vaccines, we avoid diseases that might have killed of a substantial number of us. On the other hand, without vaccines, we avoid the injuries especially of young people who our future relies on.

The current health policies really emphasizes the avoidance of premature death (even of a few months) of elderly at the expense of sacrifices of the younger generations. Even without vaccine injuries, the policies are injuring future prospects the youngest adults, and the adolescents and children. The policies are denying the youngest group a normal education and socialization development of group interactions as at schools and playgrounds. The policies are denying the adolescents and adults of the kind of relationship development that can lead to building healthy families, or to building strong professional networks that will benefit them in the future.

Demanding sacrifices from the younger generation will inevitably harm everyone. Ironically, the stated policy goals of protecting the older generation will eventually give them great harm as a result of the weaker economy and more volatile political environment. A weak economy and volatile political scene will not be able to afford to continue to lavish the current benefits that the seniors enjoy. It may be poetic justice, but it could turn out to be a justice at an unprecedented scale, one that would be impossible without modern expectations from medicine and science.

The current policies for the pandemic have the potential for catastrophic consequences at a scale where there would be no civilization to discuss what might have gone wrong, let alone suggest an alternative.

More likely is a more hopeful outcome where we will recognize the mounting problem in time to adjust our policies and that will require us to reassess our values. We will have to confront whether there are outcomes worse than death.

The current policies have the presumption that the prevented death may be your own or someone you love. This presumption has a foundation of our attitude to modern medicine. Everyone views the primary value of modern medicine is its promise to save their own lives. We celebrate the success of medicine especially if the life saved is our own or of someone we love.

It is also this promise that funds modern medicine with our acceptance of health insurance premiums and of government budgets devoted to medicine. The premiums are acceptable at a personal level because we expect we will use medicine to extend our own lives. The government budget is politically acceptable because we don’t want to hear about deaths, particularly of sympathetic characters.

I question whether this is an appropriate goal for medical practices and public health policies.

There is clearly a harmful side of modern medicine. Modern medicine is killing people who otherwise might have lived longer if they had not sought medical treatment. In my life, I have learned the premature deaths of people I at least met at one point. These deaths were the result of complications from surgeries or from pharmaceuticals for conditions that did not have an immediate threat of death.

Modern medicine does fail, not just in failing to save the life from some deadly condition, but also in causing the death of someone who otherwise was not at risk of dying. A sizable proportion of deaths are the direct results of errors in medical practice. More deaths are indirect such as suicides following antidepressant usage, or of overdoses of opiate-related medications. There are deaths attributable to vaccinations.

The real risk of the current universal imposition of restrictions and mandates for a medical issue is that will draw widespread attention to the current state of the medical practice itself. The mere existence of these inconvenience will cause people to ask questions to a topic they largely ignored: modern medicine. The restrictions free up a lot of time for people to direct their attention to the subject. It may start initially as a distraction, a form of entertainment, to learn of the shortcomings of modern medicine. People will learn more about the downsides and the misdirected priorities of benefiting the elderly at the expense of the younger generations. At some point, they may decide that this is not a system they want to continue to support. The bubble will burst.

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