Some premises we don't examine, we just assume. Such as the premise that everyone wants us to be healthy. Well, our mamas and papas want us to be healthy, because they love us. Our friends, children, lovers, all share the same desire, to keep us near them, and in good health, because they care. We cannot expect our employers, our physicians, or our health insurance companies to have the same warm fuzzy feelings for us. But we do believe our health is in their best interest. Our employers want us to be productive; our physicians have taken the Hippocratic oath to "prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone", and they take pride in keeping us well; and our insurers, well, surely they want to keep us healthy, if not for the sake of our general well-being, then for the sake of keepings the bills down.
Except this premise is seldom proven by everyday actions. For example, consider exercise. It's good for you, right? It increases your muscle mass, improves your cardiovascular ability, and quickens your metabolism. All good consequences, associated with better health. And yet no one ever pays you to join the gym, or reduces your health payments if you do. And while cigarette prices never go down, no one ever directly fines you for smoking, even though the perils of puffing up tobacco are well known. True, it would be a tad freaky if there was a health police out there, but it's almost as freaky to think that nobody cares. At least not enough so as to support our health-promoting habits, and ensure we make it to happily ever after in mint condition.
I work at Princeton University's Center for Health and Wellbeing, surrounded by labor, development, and health economists. They are trained to make numeric models of anything, including the chilling monetary value of suicide. It is economists who drive corporate policies and determine government spending. My economist colleagues would not just ask if there's a good way of keeping one in ship-shape. They would also ask if it's cost-effective. Trying to calculate the value of preventive medicine and case management, economists ask questions such as - what is the price of smoking, and whether it is economically efficient to get people to quit. Smoking is the number one cause of preventable deaths, and is associated with morbidity, so it's probably in the best interest of the health system that people do not smoke, right? Wrong. Smokers' health deteriorates sooner, and they are more likely to suffer from diseases such as throat and lung cancer, emphysema and chronic obstructive pulmonary disease, all costly to treat. On the other hand, they die younger, saving their insurers years of medical bills, because medical expenses increase as one ages. So if it all evens out, then your health insurance is indifferent to whether you smoke or don't smoke, live or die.
Speaking with M., an experienced consultant who has spent many years as a health analyst on Wall-Street, and who prefers to remain anonymous because she is currently a health industry entrepreneur, was quite the eye opener for me. Turns out I'm still incorrigibly naïve after all these years, because I was surprised to find that the only thing driving the health industry, and it's an industry, just like, say, the weapon industry, is money.
Employers, for example, want you to be healthy. Not because they care, but because the sicker you are, the higher your medical bills, the more the health insurance company charges from them. Likewise when their retired employees get ill, which means employers have an incentive to either make sure their employees stay healthy into retirement, or move on to another job before they age. Hospitals want you healthy too. And you would never guess why. It's because medical bills are hard to collect, especially from patients. And the higher the bill the lower the hospital's chance of ever laying their hands on the money. As simple as that.
So if these institutions want us healthy, what is stopping them from making it easy and worthwhile for us to maintain a healthy lifestyle?
Turns out that it is easy to know, say, that a 24 year old woman who takes up smoking, will spend, on average over $86,000 on this bad habit. But it's not as clear to tell how much money the system (whoever this vague term may represent) would save by persuading this hypothetical woman, or the very real, if bigger than life, Cruz, to permanently put out her Virginia Slim. Harvard's David Cutler shows that even when there is a clear bottom line benefit to an intervention, such as managing chronic diabetes patients' disease, the cost of providing managed care (all those nurses and case managers, people monitoring patients' condition and reminding them to make their medication), is balanced out by the benefit. If interventions are costly, and the benefits from them are very long term (as in, increase calcium intake now, incur less hip joint fracture at old age), probabilistic (because some people will break their hip joints, in spite of calcium supplements), or just not do not carry a high price tag, then why should anyone pay now to make us better is some vague future? In this case, it takes a saint to foot the bill, and saints, unfortunately, do not abound.
The one person who would emotionally benefit from you feeling well and financially benefit from you earning well into old age. And that person is you. It is neither a person in a white robe supporting you on this journey to health and wellbeing, nor your medical insurance. Applauding from the sidelines will be a small yet determined group of people who unequivocally want us to be well, because they want to keep hugging us, if for no better reason. So rather than counting on some benevolent caretaker to gaze into Penelope Cruz's chocolate chip eyes and ask her to quit, it's up to the beautiful lady herself, or to Havier Bardem, to make sure she sticks around forever.