By JEREMY SHANE
What’s behind the coming health care reckoning? Most industry leaders have their preferred list of culprits: not us! Left-leaning critics blame large insurers, drug companies, and private equity firms. Take the profit and self-dealing out of health care. Those on the right blame excessive regulation, poorly-designed insurance markets, or limits on individuals’ ability to pick their own coverage. Debates yo-yo between these views in a political stalemate. While the views are diametrically opposed on solutions, they share a belief that financial issues are the root cause of systemic dysfunction. That manipulating how clinicians are paid or insurance is structured can improve health outcomes.
A half century into efforts to fix health care, it is clear that both views are wrong. Americans’ healthspans are shrinking while costs spiral upwards thanks to chronic disease. Progressively worsening illness throughout adulthood eventually explodes in multimorbidity, driving cancer and dementia, and protracted hospitalizations. Clinicians know this, with their well-worn chorus of “if only” laments. If only we could reward prevention instead of treatment. If only we intervened earlier before advanced pathology takes hold. If only clinical care was not fragmented. If only people had a direct stake in their longer-term health. Yet the debate in Washington DC, even shaken up by the MAHA movement’s focus on chronic issues, regresses into an interminable blame game, and conflicting ideas about how Congress or CMS could end the madness.
It is time to break the cycle and say clearly what we know to be scientific fact. It’s impossible to use a system built to solve acute issues to also solve multi-decade, highly variable disease threats. Yet this presumption, that one system can do it all, addressing everything from colds to car crashes to cardiovascular issues to cancer, is so deeply ingrained in our thinking as to escape scrutiny.
It is folly to continue. We need two systems, not one — the first for routine, emergency, and elective treatments and the second to confront long-term, complex challenges. Absent this change it will take far longer than it should, and cost far more, to decipher chronic issues or create economic arrangements that can bring forward the ultimate value of preventing disease.
Resetting Assumptions
It’s illuminating to focus on the scientific drivers of disease rather than the financial after effects. It becomes clear why Medicare Advantage is imploding, and no, it’s not because CMS changed payment rates. Since 2000, the percent of Americans entering Medicare with multimorbidity has jumped by two-thirds, from a quarter of new entrants to over 40%. Software may be eating the world but multimorbidity is eating Medicare, Medicaid, and private insurance, and with it, most Americans’ healthspans.
Most Americans now live a decade more than their grandparents, only to spend all the additional years, and then some, in poorer health.
More years alive but fewer years in good health is hardly a bargain. Shrinking healthspans impose an immense socioeconomic cost, slowing workers’ earnings (thanks to higher premiums and co-pays) while requiring greater health outlays in the workforce and retirements. In combination, these trends constitute the most regressive tax on middle-income and poorer Americans’ wealth. Solving multimorbidity, thereby increasing healthspan, would be the largest and most progressive policy imaginable, unlocking $15 trillion or more for Americans fifty and older. Most of that gain will accrue to middle-income Americans, something that liberals, pro-abundance centrists, MAHA activists, and low-tax, free marketeers should all rally behind.
It’s ironic, then, that no agency tracks healthspan or sets goals to increase it. So the health debate is shaped by statistics that are collected, including total spending and lifespan, even though both metrics are results of upstream choices, rather than leading indicators, and misleading. Spending data, for example, reflects the inefficiencies and inequities that result from using an acute care system to solve long-term issues, incrementally ratcheting up treatments to keep pace with accelerating pathology. Life expectancy metrics also paint an incomplete picture, reflecting the disproportionate impact of poor prenatal and postnatal care and high rates of accidental and addiction-related deaths among adolescents and young adults. All of these issues warrant attention and resources but even if magically erased, would do little to reverse the larger sources of disease burden, cost, and systemic dysfunction.
Healthspan metrics would illustrate the magnitude of chronic disease prevalence over time, providing early indicators about future disease risk and spending. Instead of looking at how much we spend by population segment, we would track the number and type of conditions among population segments (i.e. zero, one, two, three, etc.). This allows us to move from static snapshots of chronic disease to a more dynamic view illustrating how fast incidence and prevalence is changing and in which combinations of conditions. When the widely-respected Rand Institute looked at this question in 2017, it found that the 30% of Americans with multi-morbidity account for two-thirds of total health spending. An additional 30% have one or two conditions, and an unspecified portion of the remaining 40% who might have significant risk of future disease.
These statistics highlight how lopsided disease burden becomes as chronic disease progresses into multimorbidity. The pathway across a person’s lifespan is more like a cascade than a series of distinct diagnoses. It is a decades-long war of attrition affected by innate and environmental factors with pathology accumulating over time, chipping away at internal defenses, spilling over from one organ or system to another, gaining momentum from age-related degeneration, while feeding it.
It is senseless, then, to debate the relative value of treatment versus prevention. We have to do both, working across all stages of the chronic disease cascade, reversing disease among those who have it, helping everyone maintain a better health trajectory, and broadening efforts to predict future risk and prevent onset.
Efforts to increase healthspan can be measured in absolute terms, as well, looking at the multimorbidity rate of people entering Medicare and the median age of multimorbidity onset. The first tells us if we are making progress in postponing the chronic disease cascade, while the latter tells us if we are doing so on a broad scale. All of these metrics could also be sliced by demographic or other factors, and to understand correlations in timing or severity of situations that are more or less likely to cause multimorbidity.
This brings us back to the heart of the problem with today’s system, health insurance in particular. Most of the system’s value is in forestalling future disease, whether or not that requires costlier or cheaper interventions now. However, little of what we pay for health coverage protects against future disease risk. Some portion provides insurance against the risk of low-frequency, high cost events like a traumatic accident, but most of the premium is a kind of annual prepayment plan to access a network of clinicians and hospitals. Most of these funds get used to treat incremental symptoms, especially, as we saw previously, for advanced multimorbidity.
The system works exactly opposite to the way it should, undervaluing near-term interventions that, while costlier, could have better long-term effects while prioritizing expensive treatments to deal with advanced disease that have lower long-term ROI. There is no way to reward payors, clinicians, or individuals to achieve better long-term outcomes, and no means to bring forward the future value of predictive or preventive efforts, quantifying and tangibilizing the value created over time from avoiding disease.
Using Life insurance to Solve Multimorbidity & Increase Healthspan
Notwithstanding all the problems, is it possible to build a new system focused on chronic disease?
Yes, if we are strategic about it, focusing first on metabolic issues. Starting here makes sense since metabolic issues are such significant contributors to multimborbidity, cancer, and dementia risks, and the tremendous advances in medical technology to treat it. GLP-1 drugs are game-changing, providing systemic value beyond obesity and diabetes, and seem destined to only improve as new combination therapies are developed. This, in addition to already effective surgical approaches. Neither treatment is a silver bullet, and both require holistic clinical expertise and ongoing medical and behavioral support, but we can now say with confidence that it is possible to reverse metabolic disease.
To support this, we need a financial framework that aligns individuals, clinicians, and insurers around long-term outcomes, not only to treat disease, but to help people maintain gains for decades while accelerating capabilities to predict and prevent disease.
That’s why the right financial structure to solve chronic disease is life insurance. Its long payback horizons enable investments to reverse or prevent disease plus ongoing efforts to preserve gains and predict future illness. Where health insurance focuses on input costs, life insurance relies on the steady accumulation of good outcomes. The cost of tactics used in any given year matters less than the benefits generated over many years.
This is a revolutionary change, allowing everyone — individuals, payors, clinicians, and productmakers — to be aligned around outcomes over time, and to share in the value of lower health spending. Most importantly, life insurance provides a mechanism to reward individuals for their progress in improving their health trajectories. Individuals can earn payments tied to health goals, which can be deposited into the policy’s savings component to grow tax-free. Validating individuals’ progress will require a consistent approach to collecting longitudinal medical and non-medical data, including blood samples, supercharging efforts to develop and validate predictive and preventive measures.
It’s a profound shift to reimagine using a product we think of as protecting against early death to be increase healthspan. But it makes sense given a disease threat that kills slowly, then all at once. Almost a decade ago, visionary Clayton Christensen (and his co-authors) wrote in The Innovator’s Prescription, that the ideal entity to disrupt the existing system is:
“… one whose dominant profit formula makes money by keeping us healthy, not just by making us well. It must be one whose tenure with us is long enough that it would be willing to spend more now, when necessary, in order to save even higher costs down the road. It must be a system whose participants are motivated to spend what is needed—so that neither money nor health is wasted. And it must be capable of acting with considerable speed.”
Stripping chronic disease treatment from sick care, and repackaging it with life insurance ticks all four of Christensen’s boxes. In a future post we will look at how, practically, a new system can be built. For now, it is sufficient to realize that the status quo, and the circular debates its incumbents encourage, are not set in stone. There is a viable alternative; if we are willing to think beyond what exists, we can escape what’s holding us back.
Jeremy Shane has spent his career in consumer health tech (including stints at Healthcentral and WebMD) Edtech and energy. He’s currently a fellow at the USC Schaeffer Center for Health Policy & Economics.
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