Last year I had the privilege of working with the Ralph Lauren Center for Cancer Care in New York City. They provide care for not only the poor with no insurance, but also many under-insured. Their patients include hotel workers, cab drivers, and other working people who were struggling to make ends meet even before being confronted with a serious illness.
An article published in 2016 by the Kaiser Foundation and the New York Times reported one in five working age Americans with health insurance said they had problems paying medical bills. 63% reported using all or most of their savings and 42% took an extra job or worked more hours to pay their medical bills. This is also seen on crowd-sourcing sites to raise funds. A search on gofundme.com showed nearly 43,000 causes for "medications US". To help readers outside the US understand this situation, most say something like this:
"C is a precocious 7-year-old who has recently been diagnosed with Type 1 Diabetes. On a road trip home from visiting family in Atlanta she became very ill and the family was forced to stopped at the nearest hospital The hospital was not equipped to take care of a small child and her health was quickly declining ... so she had to be air-lifted to a facility with a PICU where she spent 7 days in the hospital recovering from a severe Diabetic Ketoacidosis. Although having medical insurance, the emergency transportation billed an additional $39,000 and her hospital stay was over $20,000. C is being raised by her single mother who is an elementary school teacher and the cost of overwhelming medical bills, co-pays, and daily medications has put a tremendous financial strain on her mother and everyone who helps support her."
Diabetes is a particularly burdensome chronic disease and it is costly to manage. Metformin is a common treatment for Type 2 Diabetes, currently used by over 14 million Americans.
Cost of Metformin for 100 500mg tablets:
US (Pharmacy Checker): $21.43, with coupon and discount club to reduce cost, otherwise about $48.
NZ (local pharmacy): $5.00 (NZ) or $3.50 (US) for New Zealand residents
These costs alone may not feel particularly burdensome, but the stress of paying for the medications, test kits, and doctor visits is increased with the complexity of insurance, discount clubs and coupons, co-pays and deductibles.
Managing is costly and stressful, but not managing costs more. Unmanaged, diabetes progression can lead to blindness, kidney failure, and limb amputations.
"Type 2 diabetes is a major burden for the payer", began an article from the National Institutes of Health published in October 2016. Wow. How about major burden for the patient?! In spite of this dodgy beginning, the article had redeeming value in revealing the cost-effectiveness of medication adherence and lifestyle interventions. Type 2 diabetes is largely preventable with physical activity and a healthy diet. Consider the following comparisons:
Japan
Not surprising Japan has a lower rate of diabetes, as they also have low rates of obesity and other related illnesses, and they enjoy a longer life expectancy than most countries.
I asked a
friend in Japan about his children's exercise programs. He replied the public
elementary school in Tokyo where his two daughters attend has a regular
45-minute physical exercise program 3 times/week. In addition, his daughters
enjoy swimming and rhythmic sportive gymnastics so likely they are meeting the
World Health Organization (WHO) recommendation that children 5-17 engage in 60 minutes of moderate to vigorous activity
DAILY. His son attends a private kindergarten, which in addition to
daily typical play activity like running in a garden, jumping rope, etc., also
has an outsourced training coach for a 60-minute physical exercise program
twice/ month. Outside of school, his son enjoys swimming and tennis, so likely
he is meeting the WHO recommended daily activity level, too.
United States
US national recommendations on physical activity for children are consistent with the WHO, but only one state is meeting this.
More typical is South
Carolina, which mandates at least 60 minutes of physical
education per week in grades K-5,
but it does not require daily recess. The state also mandates that high schools
provide physical education to students (no time limit given), but there is no
requirement for middle school/junior high schools. Predictably, South Carolina has one of the higher rates of obesity. According to
the State of Obesity Report published
in 2016 by the Robert Wood Johnson Foundation, 32.9% of South Carolina children
are overweight or obese.
Another example: A family member's first grader in Colorado has two 20-minute recess periods per day, plus a regular 40-minute physical education class three times per week. When the family moved there recently from Texas, they noticed fewer overweight kids in the school, and the State of Obesity study supports their observation: Rates of overweight and obese children in Colorado and Texas are 27.2% and 33.3%, respectively.
South
Carolina and Texas are not the worst performing states. That would be Tennessee where 37.7%
of children are overweight or obese. The best performers are Utah and Oregon,
which are not exactly impressive with rates of 19.2% and 20.3%, respectively. Coincidentally, Oregon was the only state that
met national recommendations for weekly time in physical education in 2016.
If one-third of children were failing math, there would be massive reform in
the math curriculum. One-third of US children are failing to be physically fit,
so perhaps it's time to reform the physical education and activity curriculum.
New Zealand
The
disparity between New Zealand and Australia illustrated in the above data from the World Bank is believed to be attributed to the
difference in their minority populations which have three times the incidence
of obesity and diabetes:
% Māori (NZ) / %
Pacific
Aborigine (AUS)
Islander
New Zealand
15%
7%
Australia
3%
<1%
To address this disparity, the Whānau
Pakari Programme conducted home visits with a comprehensive assessment (medical, dietary, physical and psychology screen) and advice for 239 overweight adolescents
in the lowest quintile of a rural community, which was also 45% Māori and 3% Pacific. Weekly, family-based group sessions to support healthy lifestyle changes included cooking classes, virtual supermarket tours, growing vegetables, sports and physical activity, and psychology sessions. Did this make
a difference?
Baseline Mean BMI Standard Deviation Score (SDS) was 3.12 (standard deviation =0.60, range 1.52 - 5.34). The 138 participants who completed the 12-month program averaged a decrease of 0.18 SDS, and the 22 participants who attended at least 70% of the sessions averaged a decrease of 0.22 SDS, moving some out of the obese BMI range and into the overweight or normal weight ranges. Will they all stay at a healthy weight for their entire lives? Not likely, but this is a start in breaking the legacy of obesity.
New
Zealand is also addressing obesity and promoting healthy lifestyles for all with their
"Green Prescription" program. If a patient wants ongoing
support to increase their physical activity and improve nutrition, the GP or
practice nurse provides the patient with a Green Prescription (GRx). The script
is forwarded to the nearest GRx provider who encourages the patient to become
more active through:
- monthly telephone calls for 3-4 months or
- face to face meetings for 3-4 months or
- group support in a community setting for 3-6 months.
Face-to-face
meetings are free and normally held in a sports complex setting where the
patient is offered reduced rates to join other programs.
Cost
Programs
and interventions have costs. The alternative,
doing nothing, also has a cost. The US Center for Disease Control (CDC) projects
the healthcare costs of an obese person to be 42% higher than a person of
normal weight. Applying this for New Zealand, where the annual healthcare cost
per person is about $4000 per year and the Ministry of Health expects that cost to rise 5% annually over the next 40 years:
How to
finance healthy weight initiatives? The Sugary Drink Tax introduced in Philadelphia (population
1.6 million) in January 2017 raised $79 million its first year by taxing 1.5
cents per ounce of sugar-sweetened drinks. Perhaps some of this tax money will
pay for physical activity programs.
The
Sugary Drink Tax is being debated in New Zealand and many regions around the
world. Sanctions work. The US federal
cigarette tax was hotly contested when it was doubled in the 1980’s, but most now agree
it has achieved the desired result of reducing smoking. Public smoking bans and anti-smoking education financed by the Master Settlement Agreement with tobacco companies in the 1990's also helped. Taxes engender better choices, but need to be complemented with public health education and changes in systems which have contributed to the problem such as school physical activity programs.
