OPINION: Bob Davis: Carrots and sticks

April 30--My Obamacare rewrite committee gathered at The Star's offices earlier this month to take a crack at reforming health care in the United States over lunch.

In addition to your faithful correspondent, the panel was made up of Dr. Terry Phillis, an Anniston urologist, and Darin Sims, managing partner of Anniston's Pinnacle Research Group.

Our challenge was to craft a replacement for the Affordable Care Act (aka Obamacare) in 90 minutes or less.

Spoiler alert: We didn't. As President Donald Trump said in February, around the time his proposed Obamacare replacement crashed and burned, "Nobody knew health care could be so complicated."

Indeed, Mr. President, indeed.

The focus of the conversation started at a basic level. Both Sims and Phillis agreed everyone should have the opportunity to access quality health care. The question, though, is what should health insurance cover -- only life-threatening ailments or something more expansive?

"We treat every part of your life," Phillis said. "We think everybody should have access to health care ... but what is an illness?"

Phillis offered examples of what he described as the Affordable Care Act's ineffective rules that create unreliable electronic medical records and its demand for unnecessary and expensive diagnostic tools to replace the ones that were working just fine for his purposes.

Post-Obamacare, Sims said he saw his family's insurance costs rise exponentially with no real payoff. His Blue Cross/Blue Shield of Alabama premium rose by 69 percent in the first two years and his deductible increased from $600 to $6,450.

However, our discussion centered on encouraging Americans to lead healthier lives that would in turn lower the costs of health care.

A few statistics to consider:

-- According to a 2014 World Bank analysis, the United States spends $9,403 per person on health care, far more than almost every other nation with a developed economy.

-- According to the CEO of a large grocery store chain that created an effective company wellness program, about three-quarters of all health costs can be attributed to cardiovascular disease, cancer, diabetes and obesity.

-- According to the Centers for Disease Control and Prevention, Alabama ranks among the worst 15 U.S. states in rates of cancer, heart disease, respiratory ailments, diabetes and kidney disease.

-- Numerous studies, including one from the Alabama Department of Public Health, indicate about one-third of the state's residents are physically inactive, meaning they don't regularly exercise. About one-fifth don't eat five or more servings of fresh fruits and vegetables daily, a key indicator of a healthy diet. About one-quarter of adults in Alabama smoke.

A good start to making health care more affordable would be to discard bad habits, Phillis and Sims agreed.

That's not so easy, Phillis said. He offered an illustration to make his point. For example, he might see a patient whose preliminary tests indicate she is on the cusp of a diagnosis of diabetes.

He sits down with his patient and suggests some changes: losing weight, changing diet, more exercise. Many times, however, the patient will simply shrug and say that she's not going to do that. Just give me the pill or the surgery or the whatever, she will say. Phillis said the current system's financial incentives discourage those kinds of conversations in favor of the pill or the surgery or the whatever.

Dr. David Becker, a professor at the University of Alabama-Birmingham School of Public Health who specializes in health-care organization and policy, said via email: "Going to the gym five times a week, limiting fast food, cutting down on snacking -- all of that is hard. Taking a statin or anti-hypertensive is not.

"There is also an element of risk-aversion at play as some patients (and their physicians) don't want to run the risk of waiting to see if lifestyle modifications will work."

Sims sees a national health-care apparatus focused more on the "cost of sickness" and less on healthy behaviors that keep most people out of a doctor's office.

Incentives that encourage Americans to lead healthier lives matter. "Everybody understands money," Sims said. "Those shouldering the burden of the plan should not be forced to subsidize malingerers," he added in a follow-up.

The Affordable Care Act's incentives record is a mixed bag. Insurers are allowed to charge smokers 50 percent more for coverage than non-smokers. However, they aren't allowed to "take your current health or medical history into account," according to HealthCare.gov.

Under Obamacare, employers that offer health insurance can raise or lower premiums by as much as 30 percent depending on whether or not employees participate in wellness programs.

The U.S. House of Representatives is considering a bill that would expand how employers can build wellness incentives into health insurance. U.S. Rep. Bradley Byrne, R-Fairhope, is promoting the measure, which would grant businesses more latitude in creating healthy employees.

Still, said UAB's Becker, "The efficiency of incentive payments will depend on the proportion of the population who adopts a healthy behavior in response to incentives relative to the proportion already engaged in the behavior."

Those kinds of voluntary changes to create a stronger and less expensive U.S. health-care system are in the hands of citizens and not government.

Bob Davis is editor and publisher of The Anniston Star. Contact him at 256-235-3540 or [email protected]. Twitter: EditorBobDavis

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