Recently, I found myself in the middle of a contentious debate on Larry King Live sandwiched between President Obama's longtime personal physician, Dr. David Scheiner, and Dr. Ron Paul, the libertarian Republican member of Congress from Texas.
Dr. Scheiner described his disappointment with President Obama for not supporting single payer health insurance as part of health reform, saying "Continuing private health insurance is crazy." On the other end of the spectrum, Congressman Paul wants to drastically limit the size and scope of the Federal government (a few days ago, he was the featured speaker at a John Birch Society luncheon in Houston).
These are false choices, a microcosm of the health reform debate between the traditional left wing policies of big government as the big teat taking care of everyone and the right wing policies of small government and survival of the fittest. We can transcend our divisions if we think more multidimensionally.
I want to focus here on an example of how my colleagues and I were able to bring together some of the most conservative Republicans and liberal Democrats across the political spectrum at the highest levels to work together to change Medicare coverage, how we're doing it again, and the lessons we learned that can enable health reform to be truly bipartisan.
For the past 32 years, I have directed a series of research studies showing that changes in diet and lifestyle can make such a powerful difference in our health & well-being, how quickly these changes may occur, and how dynamic these mechanisms can be.
We used high-tech, state-of-the-art measures to prove the power of simple, low-tech, and low-cost interventions. We showed that comprehensive lifestyle changes may stop or even reverse the progression of coronary heart disease, prostate cancer, diabetes, hypertension, obesity, hypercholesterolemia, and other chronic conditions that account for at least 75% of the $2.1 trillion in health care costs.
I thought that when we published our findings in the leading medical journals that this would change medical practice. In retrospect, that was a little naïve; good science is important but not sufficient to change medical practice. Despite the talk about evidence-based medicine, we really live in an era of what I call "reimbursement-based medicine"--it's all about the Benjamins.
I realized that it wasn't enough to have good science; we also needed to change reimbursement. We doctors do what we get paid to do and we get trained to do what we get paid to do. Therefore, if we could change reimbursement, then we would improve both medical practice and medical education.
Thus began my 14-year epic journey to persuade Medicare to cover intensive lifestyle changes for reversing heart disease. This culminated in achieving some coverage last year in the "Medicare Improvements for Patients and Providers Act of 2008" (Public Law 110-275).
Beginning in 1994, I was able to enlist the strong personal support of both Bill Clinton when he was President of the United States and Newt Gingrich when he was Speaker of the House for the idea that Medicare should cover programs of intensive lifestyle changes for reversing heart disease, not just preventing it. This was at a time when relations between Clinton and Gingrich were highly acrimonious during the midterm elections.
We also had the strong personal support of both liberal Democrat Rep. Charles Rangel (D-NY) and arch-conservative Dan Burton (R-IN), who joked at a press conference at the Capitol ten years ago that this was the only issue that they both agreed on. They even co-hosted a bipartisan Congressional retreat in 1999 in which all members of Congress were invited to learn how to improve their diet and lifestyle. We also had the support of many other members of the Senate and House on both sides of the aisle, along with the president of the AARP, the Chief of Medicine and the Chief of Preventive Medicine at Harvard Medical School, the head of the American Board of Internal Medicine, and many others.
And it still took us 14 years. As Secretary of State Hillary Rodham Clinton said in a recent interview with Fareed Zakaria on CNN:
ZAKARIA: Speaking of -- final question -- speaking of hard negotiations, what message would you have to the Senate Democrats who seem to be holding up the passage of a comprehensive health care bill? Or are they amending it in ways that are useful and productive?
CLINTON: Well, actually, I think that it's a very healthy process that's going on. They are having to hammer out all of their differences, and there are serious differences in viewpoints, for example. But what the president has said and what I believe is the right approach is that this can't be put off any longer. I mean, it's a little bit like what I was saying about climate change....
You know, in '93, for example, Fareed, I had a man who became a friend of mine, but I didn't know him at the time - Dean Ornish. He came to see me, and he said, look, I have proof...
ZAKARIA: This is the doctor...
CLINTON: Who did a lot of work on cardiovascular health. And he said, "We have proof that changes in diet, stress reduction, exercise are as effective, if not more effective than medical interventions in lowering people's overall threat of heart disease." He said, "But I can't get Medicare to pay for somebody going to an exercise class or to pay for a nutritionist to come to their house and talk to them."
Well, we worked and worked on that all through the time my husband was president. And then finally sometime during the Bush administration, the Centers for Medicare and Medicaid, CMS, said, "OK, fine, we'll begin to pay for this."
Well, it shouldn't be that hard. You know, we're more than happy to pay for a pill or pay for a procedure. How do we change behaviors? How do we convince, you know, the medical establishment to do that?
For example, in 1995 I met with Bruce Vladeck, Ph.D., who was the Administrator (director) of Medicare at the time. In that meeting, Dr. Vladeck said, "Dean, before I'll consider doing a Medicare demonstration project, you first need to get a letter from the director of the National Heart, Lung, and Blood Institute of the National Institutes of Health stating that it's safe for older Americans to walk, meditate, quit smoking, and eat fruits and vegetables." I was incredulous, but we did.
I understand those who think that single-payer health care is the way to go. However, after needing 14 years to get Medicare to do something as obvious as paying for intensive lifestyle changes scientifically proven to reverse heart disease despite the strong personal support of those at the highest levels of government and the leading experts in the scientific community, I share the Republican concern about greatly expanding the power of the Centers for Medicare and Medicaid Services. I'm as deeply suspicious of big government as anyone. I'm strongly in favor of universal coverage but not single payer.
But I also understand the anger at large insurance companies that drop coverage on people who get sick or lose their jobs, or who don't provide coverage for 48 million Americans who are uninsured. Again, too much power concentrated in too few institutions often leads to abuses of power to the detriment of the American people.
There is a third alternative. The idea that changing our lifestyle can prevent and even reverse the most common, the most deadly, and most expensive diseases transcends the old left wing/right wing, red state/blue state divisions. These are profoundly human issues that we can all support, bringing together liberals and conservatives, labor and management.
For Democrats, it's a way to make true health care (not just sick care) available to the 48 million uninsured while reducing costs rather than dramatically increasing them, as I outlined in an earlier column.
For Republicans, this approach emphasizes freedom of choice and personal responsibility, not to blame people but to empower them. These are things you can do to heal yourself, to keep you and your family healthy that also, by the way, substantially reduce health care costs while improving the quality of care.
As a more recent example of the power of this approach to bring both sides together, Senator Ron Wyden (D-Ore) recently introduced new legislation, the "Take Back Your Health Act" (S. 1640) that will pay for intensive lifestyle changes as treatments, not just prevention, for these conditions as a complement to regular medical care. This legislation was co-sponsored by Senator John Cornyn (R-Tex) and Senator Tom Harkin (D-Iowa), and recently joined by Senator Sherrod Brown (D-OH). Dr. Mark Hyman, Dr. Mike Roizen, and I consulted on this legislative language.
"This is a groundbreaking bill, based on the proven idea that lifestyle changes can improve the health of those with chronic disease if people stick with a program that has that goal in mind," said Senator Wyden. "The Take Back Your Health Act gets doctors and patients invested in the success of treatment, since doctors won't be paid unless their patients actually get better."
"This legislation will provide seniors who have chronic diseases with the care coordination, training, and support necessary to make and sustain intensive lifestyle changes that have been clinically proven to beneficially affect or even reverse the progression of many chronic diseases," said Senator Cornyn. "I'm pleased to join with my colleagues in a bipartisan fashion and will continue pushing for common-sense solutions to our health care system."
"The health reform debate is not about continuing the status quo, but about changing our health care system and the medicine we do," Senator Harkin said. "This legislation will change the medicine Medicare does by reimbursing health care professionals for proven programs to address disease, including coronary heart disease, diabetes, and some forms of cancer, through intensive lifestyle change. Health reform is about giving individuals more choices and individuals should be given the option to engage in a lifestyle treatment program instead of surgery and pills."
One of the reasons why the old liberal/conservative dichotomies no longer apply is that these have been eclipsed by a larger issue: the consolidation of power. I strongly believe that the Founding Fathers of our country got it right: power corrupts, and any time you have too much power concentrated in one place it tends to get abused, so checks and balances are always needed.
And almost every day we learn of new abuses of power that occurred under the Bush administration which actively tried to disrupt the balance of power in favor of the Executive Branch of government.
Bureaucracies tend to perpetuate themselves, whether they are multinational corporations or large government institutions such as Medicare, often at the expense of those that they are supposed to serve. Too much power in any institution tends to stifle innovation.
Therefore, if we want to bring Republicans and Democrats together, then we need real health care reform by developing new paradigms for government and corporations that focus on how we can address the underlying causes of most diseases--what we eat, how we respond to stress, whether or not we smoke, how much we exercise, and the quality of our relationships. These can empower the individual to make healthier lifestyle changes rather than the false choices of increasing the power of large corporations or growing the power of government institutions, both of which make me want to rebel. Don't tread on me.
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