Moderator: Richard Lamm is the Director is the Co-Director of the Institute of Public Policy studies at the University of Denver and former three term governor of Colorado, of course. A nationally recognized expert on healthcare issues, Lamm Chairman of the Pew Health Professions Commission and a public member of the Accreditation Council for Graduate Medical Education. He is the author of numerous articles on healthcare that have appeared in national medical publications and his editorials have appeared in major newspapers including The New York Times, The Boston Globe and The Los Angeles Times. He is also the author of several best selling books that has been to Tattered Cover many times including his recent book on health care; "The Brave New World of Health Care". We are delighted to have him here tonight to discuss his important new book "Condition Critical: A New Moral Vision for Health Care". Please join me in welcoming Richard Lamm.
Richard Lamm: Thank you for coming and like Heather said, thank you for supporting independent book sellers. I am trying to make sense out of a world that has invented more healthcare that we can afford to deliver to everyone. In a lot of ways this is a wonderful success story. You know, there is we in this room have on an average more life, more health, ahead of us than any generation could ever dream of. The average person in this room can reasonably expect to spend in retirement more time than people used to live not that many centuries ago. And so in last century we added 30 years to life expectancy. So in a way this already is a good news story that is it's very important that we get right very important that we get right. One of the things that I spend a lot of time I suppose thinking about is that all during my professional lifetime; healthcare was grown at two and a half times the rate of inflation. When my wife and I got married in 1963 the average - I know this sounds amazing but the average hourly income of America was $2.97 and healthcare was a $197 per capita which means that the average American earning $2.97 an hour had to work until mid January to pay their healthcare costs. Now the average American worker has to work until mid March to pay for his healthcare. So 178 hours this is to pay for their healthcare. So almost everything in the family budget like, the percentage of their income that you spend for a house or a car or a drier and washer and things like this has really dramatically gone down, the percentage of your time, but in healthcare it has gone from mid January to mid March. And what I argue is there is a whole range of issues involved in getting something that's growing to two and half times the rate of inflation down to not more than the regular rate of inflation. But we really haven't even started talking about and that there really needs to be a dialogue about, because we have some trends that are compounding this problem. Those trends obviously are an ageing society which is again good news. By the way of that 30 years of life expectancy that we added to our century, only five of it had anything to do with allopathic medicine. That the great enemies of death and disease in this society have been the public health people, the great enemies in death and disease have been things like clean water the biggest thing we could do in the whole world of course would be to get clean water. But it's been refrigeration that allows us not to salt our food is, meat in particular as much and it's been it's been screened windows to keep mosquitoes out. All kinds of other public health measures like that. But we have added essentially the equivalent of two and a half days a week that your life expectancy. Because essentially you say that you have on an average, again there is no guarantees, but you have on an average, the average American and the average person in the developed world has has a two and half day bonus every week that their great grandparents didn't have. So we really are talking about a success story, but that has now become a challenge. The second trend that's out there is just the galloping medical technology that we are the beneficiaries of. You know motors that are tinier than a hair that can go through your circulatory system. I was in Japan looking at the healthcare system and I a wrist watch that if I were wearing it and had a heart attack, it would automatically dial 911 and phone the ambulance in on the second floor of the hotel, you know. And and thousand other things that are also the miracles of medicine. And then the third sort of new factor is but the new factor only in the sense of the last sort of my generation and beyond, decidedly galloping expectations of the American public, where as soon as I turn 65 I expect Medicare to buy any one of those watches if I have any kind of heart condition. So you put those three things together, the ageing society, the medical technology and the expectation that it presents us with I think a real challenge. If we are not going to turn our entire economy over to healthcare and then we have to think about the costs out have I forgotten, they are now 44.4, the new figures, now 44.4 million people that are not covered by the basic health insurance and I don't need to forget them at all, in fact one of the things I argue in terms of the new moral vision is that you know we we have to recognize and I endlessly find a point now that the United States denies more healthcare to more people than any other developed country in the world. And so when people say well, we don't want rationed healthcare, at least from the macro level believe me, we rationed healthcare. And so we have these multiple challenges, we got to at the same time we are trying to from a social justice standpoint; it's my opinion, social justice standpoint cover 44.4 million people who are outside the system. But then we have to do this within a context that recognizes that the volcanic upward pressures that are affecting healthcare are going to require us to make a series of decisions that are politically difficult. I don't think that they are you know when you still think that we are still going to be the beneficiaries of a wonderful system, the kind of limits that I am talking about in healthcare I think are real. But we still are quite, you know we still have enough money in this country to be able to give everybody most the living healthcare that they need. One of the things that I talk about in the book is and I think it is sort of added on with this problem it's what the scholars call substituted mortality and substituted morbidity. And I would like to spend a minute on that because I think that's sort of key to that kind of dilemmas that we are faced with. And substituted mortality substituted morbidity is that my generation of physicians who have been wonderful have sort of dramatically done away with the acute disease to throw ourselves in the arms of chronic disease. So substituted mortality and substituted morbidity is the fact that we you know we all die of something and what's happened in this in health policy is a lot of our medical miracles which we thought we are going to save money, don't save money. In fact the health economists are almost unanimous, 88 percent of them, including the last four that I saw are pointing out that medical technology is the key driver of healthcare cost. Not the only driver but the key driver. So one of the sort of haunting figures is that the life time healthcare cost of smokers is substantially under the life time healthcare cost of non smokers because they die early. Smokers die on an average seven and a half years before non smokers. But what that means is that or what I claim is likely would be if we cure cancer we all end up increasing healthcare cost, stick with me I understand. My wife had cancer when she was 42, 25 years ago. And Dottie had - frankly a very dim prognosis at the time. She had lots of lymph nodes involved but she beat it. And so do I want to cure cancer? Of course I want to cure cancer. But one of the things that from a health policy standpoint is I claim that sort of the smoking thing will repeat it, you know, that we cure cancer and you dramatically increase arthritis, Alzheimer's disease, knee replacements, everything else. Is that worth doing? I am not arguing that it's not worth doing. But you get the dilemma that we are we are tied into is that that we succeed in some thing and we throw ourselves into other diseases. A wonderful woman that teaches at Rutgers, she used to teach at Rutgers, I guess she is now in DC, named Louise Russell says, the same thing applies to preventative medicine. I work out almost every day and I really believe in keeping yourself healthy. But we are and do I believe in prevention? Of course I believe in prevention. And we need more of it and the matter of fact I will get to that in a minute. But one of the things again in prevention that she claims as you have the same questions of substituted mortality and substituted morbidity. You keep your self healthy here but you you last live long, unless you fall far more air to the kind of diseases that our human body is you know, almost inevitably subject to. So given these challenges I argue that one of the major things we have to sort of rethink is sort of the new the moral vision, first of all what healthcare what the ends of healthcare is? And second of all, how we consider such things as universal health coverage. I think that the the concept that we don't ration healthcare, that we don't want to have a any kind of rationing in healthcare, we start off by saying, we do rational health care. And that we on a population basis that we sort of have the hold people more accountable and so I am I am interested in who owns the uninsured. You can't I claim you can't ask a doctor or a hospital to treat the uninsured for nothing. I think that you you hope that they do and some Gary VanderArk, he is a very wonderful doctor here in town. Some of you must know him, who has been out so much of his life trying to organize healthcare for the uninsured. But I don't think that you know that the question of who owns the uninsured to me only has sort of one real ultimate answer and that would be the state or the nation owns the uninsured. So when you if you look at it then this sort of macro viewpoint I argue things like Governor of Florida making a big deal over Terri Schiavo should be offset by the fact that in Florida when he was making such a big deal over some body in a permanent vegetative state, that Florida had 21 percent of it's population uninsured as opposed to the 17 percent approximately nation wide. And that looked at it in that way that he should have paused and and had some feeling some broader feeling about the delivery of healthcare in a world of limited resources. So, here is what I here is what I argue, that there is a new emphasis, there is really four moral planes to consider healthcare. The first one would be self responsibility; you are your own best doctor. And that would be the ground floor of heath care. And we have to put a new emphasis on that, and all you have to do is look at the obesity figures and see that. And a number of other countries are doing this and it's easy to tax cigarettes and alcohol. But once you get beyond that it's sort of hard to do, conceptually, to try to put more emphasis on individuals and try to make them more responsible. In Great Britain they don't do open heart surgery on people unless they have given up smoking or quit smoking for at least six months. And they claim that what the elements they claim that they are not punishing people for smoking. What they are doing is they are saying you know, we have limited resources in healthcare and how do we make best use of those limited resources? And it is we know that you know, smoker's open heart surgery, your success rates are far less than anybody than than in other places. They also announced in Great Britain that they were not going to give obese people certain operations and certain heart open heart operations. And they didn't implement that. They backed away from it. But there is a number of companies in some states now, Alabama West Virginia has just started down some things; where they really try to in some of the companies they will charge smokers more for their healthcare. In West Virginia they tried to whether it's a carrot or a stick, they really tried to in the administration of their Medicaid money, to try to get people to take more self responsibility. I admit that it's hard to do. But this idea that we we can't just wait and throw our bodies on the healthcare system after abusing them I think is a really important dialogue to have. The first floor of the house of healthcare then would be the doctor-patient relationship; and I argue that the 2000 years that has served human kind well and that we have no major reason to change that, except that I am claiming that a lot of medical practice and medical even medical ethics don't take into account sort of these new realities. And most of those new realities come in at the second floor of healthcare that I argue would be insurer of a community. The idea that if everybody in this room is in the same insurance pool, that we have to find some transparent and just way of sharing that that limited pool of money. And we have not really confronted that issue before in the United States. We some how expect our insurer to pay for everything that is is beneficial to our our health. And I don't think beneficial is the anywhere near our sustainable standard. My metaphor for that would be to announce tonight that I am running for your school board and then here is my platform, I am going to say that every teacher has the moral duty to deliver everything beneficial to every student in our school district and the cost is no consideration, I am going to have you pay for it, you get the point. We just just can't beneficial is not a sustainable standard. So, in this question of sort of how we distribute a limited pool of money, I I mentioned the work of a wonderful woman named Havi Morheim that has what she calls "contributed justice". And what she is looking for is a a just method of of trying to decide if I want to if I have two headaches and I want a CAT scan, how do we decide whether our collective pool of money is well spend on giving the CAT scan after two headaches. So some more dialogue has to be had about the rules of distributing a limited pool of money. In Canada they do that by delisting things. They in Oregon they they started this Oregon health priority system where they took everything that they were doing and paying for and tried to decide what they what should be done and what shouldn't be done. And then the top floor of healthcare being the state or the nation and that would be the one that I would argue owns the uninsured, owns the duty to provide the public health system and other things like that. So that we have not one transaction in healthcare but really four moral planes on, there are four moral radiuses that need more discussion and more argument as we develop the rules of doing this. I think that that and one of the things we are going to get into in questions and answers obviously is what kind of system is the best. My argument is whatever we do; we need to sort of certain things that we have to think about doing, one of which is technology assessment. All of the other developed countries have some method of accessing their technology. In the United States we have no method of that processing technology. And its really there is you know if some body invents something or there is an article in The New England Journal of Medicine on Monday morning and by Tuesday its an entitlement to Americans. And that's just that's just unsustainable. So how to do we know when to buy a new MRI machine, or how do we know what new drug is really effective. We now have as many of you know better than I, drugs that involve might cost $30,000-$40,000 dollars and will prolong life with may be 3 months or something like that. And those are the kind of issues that I think we need more discussion on and so this idea of technology assessment. The second institution that I argue no matter what system we come up with, that we need is some sort of priorities system like Oregon. We need to we need to have a discussion, I argue for instance that there is no sensible use of the of an artificial heart. And there is a heavy burden on any body like me that goes in and tries to save others don't go there, don't go there. But I with 44 million people uninsured in this country, should we be spending federal funds to the investigating an artificial heart that was you know, we couldn't afford to really deliver in practice anyway. Harold Varmus is the former director of NIH, National Institute of Health and he has been talking here recently, doing some wonderful writing. He say you know, when the United States were spending tax payers money researching things that we have no hope of being able to deliver to people. And so I do understand the miracles of medicine are really of immense importance, but I do think that there needs to be some you have to be very careful here. But that we need to have some technology assessments and some reordering of goals. There is a conflict between expanding the floor covering 44 million people and pushing up the ceiling. There is just a conflict between two. And I argue, at least for the next short period of time in American history we should spend extra effort expanding the floor and even if it's the expense pushing up the ceiling. Something else I meant to say, but I think the best part of this is always the questions and the answers. So let me just stop there and let's have a dialogue about it, where are we going in healthcare?
