Mark Arnoldy – TRANSCRIPT
One of my most deeply imprinted childhood memories came on a day when my mom picked me up from middle school. We rolled to a stop at a red light, and I asked her a question from the passenger seat. When she didn’t respond, I looked to see why. She was trembling and tears were starting to come down her cheeks. She reached her arm over to mine and she said, “You’re going to be OK.”
I said, “What do you mean?”
She said, “You’re going to be OK. You don’t have cancer.”
In my innocence, I just realized that the intense health care tour I had been through all lead to that moment. Months prior, they found a lump underneath my chin. The lab tests were run. I toured the country and visited specialty hospitals, and surgeons removed a mass underneath my right arm the size of a softball. Until finally my mom got the call.
She heard her new favorite word: benign. But in reality, my health care tour started much earlier. I had an aggressive skull surgery as a baby to correct the shape of my skull because doctors said I would be socially unacceptable without it. I was hospitalized as a teen because I had a pneumonia that was non-responsive to antibiotics. Doctors had to physically insert a chest tube between my ribs to drain the fluid from my lungs. It extends to today, where I stand here, quite literally, because I take a weekly injection to treat arthritis that would otherwise cripple me.
And as painful as it is, I compare my mom’s experience to the experience of a mother I spoke with in Nepal seven years ago. It was a mother of a malnourished girl, and we were talking because there’d just been a new treatment introduced in her community: a simple paste that allowed her to treat her daughter at home. So I asked, “What did you do before this existed?” After a long pause, the translator responded hesitantly and said, “The mother said the only available prescription before this was to wait to let her child die.” I was stunned.
Never before had I felt such indignation, not at the mother of course. Her statement was not a reflection of apathy. It was a reflection of desperation. I’m deeply troubled by this, because I believe the way we design our healthcare systems speaks about our identities as a society. The choices we’ve made to date put the values we all share at risk.
No one would ever willingly place a mother in the position where she didn’t have a treatment for her child and no one would ever wish for a hardworking family to go bankrupt due to the cost of their medical bills in the world’s wealthiest country. Yet, these are the two health care worlds I move between. Here, a system of excess. There, a system of access. And confronting that reality created the driving question of my career: can we design health care systems that meet our moral aspirations? I’m here because we can, and it’s very easy to say that this is all just about money, to dismiss it that way.
That if people in Nepal and places like Nepal were just wealthier their health care problems would go away. But you don’t need to look beyond the failures of the US health care system to see that that’s not true. It’s undeniable that we get low value for tremendously high cost. Why? It’s a design issue. We have a more-is-better mindset, and it’s exaggerated by a fee-for-service payment structure that creates the wrong incentives. This more-is-better mindset rewards clinicians for giving excess care that satisfies patients’ desires, instead of solving for patients’ needs, even if it demands fewer medical interventions. This is extremely costly.
In 2011, we spent 226 billion dollars on unneeded prescriptions and procedures. Even worse, is that the way we pay for health care in this country has become a form of trauma itself. The leading source of personal bankruptcy is paying for medical bills, and it’s responsible for an astonishing 57% of personal bankruptcies. So you can’t really argue that this is just about money. Yet, what I find strange is that people believe that exporting this system of excess to places that are struggling with access provides an answer. We see countries all over the world combining a more-is-better mindset with the irresistible incentives of a fee-for-service model, and all they’re getting is a pretty poor nickel-and-dime approach to health care that leads their most disenfranchised in a terrible place.
Every year we have 100 million people that are driven into extreme poverty by paying for health care out-of-pocket. That’s worth saying again: health care is the driving force pushing 100 million people into extreme poverty every year. So if this system of excess that we have here isn’t going to provide the answer to places that are struggling with access, where do we look? Well I’ve had the great privilege, working over the last few years with an incredible team, trying to build health care systems in the world’s most impossible places. Places like this in rural Nepal, located 36 hours by bus one way from the capital city of Kathmandu, where people make an average of under $200 per year, and are offered very little in terms of basic services, like roads, electricity, and water. What I’ve found during this pursuit is that an unlikely idea is holding us back.
That idea is the idea of sustainability. Now I know there is risk in trying to take down sustainability, especially in Colorado, but let me explain. Very few people know that we have gone through two great eras where we attempted to define sustainable health care, yet all it led to was widespread misuse of the idea. In 1978, world leaders convened upon Kazakhstan to sign a declaration that said we would have health care for all by the year 2000. But what happened as a result was that we didn’t commit to building health care systems that worked fully for the poor; we chose a path of selective health care.
Essentially a basic minimum package that made it pretty easy to go after the low-hanging fruit. Because this in theory was cheaper and easier to execute, it became our definition of sustainability. So we lowered the bar. Then in the early ’90s, when we saw that we were very much off the mark to hit health care for all by 2000, we made another attempt. We pursued an aggressive fee-for-service approach, saying that this would only happen if the poor were put in a position where they would have to pay for each of their services.
So what you get when you put together both of these attempts is a definition of sustainability that equates to a minimum package of health care, and special rules for the poor that we would never allow to be applied to those we love. So where does this leave us? I would argue that sustainability is not a benign term as it relates to healthcare for the poor. That it’s actually led to vast failures of imagination, and it’s prevented us from building health care systems from the way they need to be built. But now we’re in a different era. I’m actually gonna just go and say I think we should just do away with the word sustainability as it relates to health care all together.
I think it’s too flimsy, it has a scarred history of being used against the poor, and we can do better. We need to move away from the errors of sustainable health care and pursue a new approach: something I call durable health care. Durability demands more than sustainability. Sustainability is based on satisfying patients who can pay. Durability is based on solving for patients regardless of their position in society.
Sustainable health care means something different for different people, but durable health care is one clear promise: it says we’ll build health care systems the poor can rely on to escape poverty, rather than be one that drives them further into it. Durable health care is also a system design that helps us avoid the failures of traditional approaches.
After years of working in Nepal, we realized that these traditional models have their failings, that none of them alone fully solve for the poor. The private sector isn’t accessed due to cost, the public sector often fails to deliver in quality, and the philanthropic sector, though it can create great pockets of excellence, never achieves the scale needed. Yet each of these sectors also has strengths.