Faith and Healthcare
Dean Lloyd: Good morning and welcome to our Sunday Forum, our ongoing conversation at the intersection of faith and public life. I’d like to welcome today an old friend, Dr. Timothy Johnson, who should be a familiar face to many of you for his many, many years as the medical editor and reporter on just about every dimension of the medical profession for ABC News, both frequently on World Wide News and the Evening, but also on Nightline, 20/20, and an array of other venues.
Timothy Johnson, often called Dr. Tim, has been offering this on-air analysis for decades now. He’s also a person of deep faith, whose quest to honestly examine his own faith led him to write a book called Finding God in the Questions, which I commend heartily to you as one of the clearest presentations of the arguments for belief in God by an authentic searcher himself that I’ve ever come across.
Tim Johnson will share some of what he’s learned with us today about what’s going on in the health profession but we’ll also talk some about his book. But the thing most pressing to him these days is what’s happening in health care and we’ll turn to that quickly, but Tim, welcome.
Timothy Johnson: Thank you, Sam.
Lloyd: It’s great to have you here. Health care has become something of a cause for you. How did you… I knew you at a moment when you were searching for what the next big focus for your life would be. How did it end up being this?
Johnson: Well, I spent most of my career at ABC talking about new developments in clinical medicine. But about five years ago, I started to realize that changes in our health care, so-called, system would be far more important in terms of the overall health of the country than any new clinical development, except maybe for a miracle like the cure for cancer.
I came to that realization because of two huge problems. One is the cost of health care. I could talk for hours about it, but I’ll just say a couple of things. We’re going to spend over $2.5 trillion on health care this year. That number is expected to double within five or six years. I said the other day in New York in a forum that health care costs will make the present financial crisis look like a Sunday school picnic someday. The inflation rate is nine percent a year versus three percent. That’s going to bankrupt the country, so we’ve got to do something about costs. But we also have to do something about delivery. It is so uneven. We kill a hundred thousand people in medical errors a year. We spend all this money…
Lloyd: Now a hundred thousand people are killed from medical errors in the United States today?
Johnson: Yes, every year.
Lloyd: That’s a boggling, mind-boggling number.
Johnson: It is mind-boggling. Can you imagine if that many people were killed in plane crashes? We’d shut down the system. We’d say, “Something is terribly wrong. We have to start all over.” But we do that in health care. So we spend all this money, twice as much per person as the average of all other industrialized countries, and we don’t get very good outcomes: 37th overall life expectancy, 29th infant mortality… We’ve got huge problems.
Lloyd: So we spend twice what the other industrialized countries do, including almost fifty million people who aren’t insured at all in the system. It’s a massively complex system that isn’t even delivering the kind of care it ought to for being in this country.
Johnson: Exactly right.
Lloyd: Why hasn’t someone fixed it by now?
Johnson: Well, that’s a complicated question. But the relatively simple answer is that there are so many special interest groups who want to keep the present status quo so that they can get their part of the honey pot.
Lloyd: A massive amount of the economy is flowing through there, isn’t it? It’s a lot of money.
Johnson: 1 out of every 6 jobs, health care industry. So any change means a change in people’s jobs. Politicians don’t like to do that for understandable reasons. There’s been a lot of vested interest in preserving the status quo, even though everybody knows it’s a broken system.
Lloyd: One always hears the argument between a competitive free-market plan and a socialized medicine plan. Is there some place in between there where we might find a way to put a program together?
Johnson: Absolutely. And in fact, I sometimes say this: I’ve come to the conclusion that it is impossible to fix the American health care system, and people usually gasp a little bit.
Then I say because there’s no system to fix. And that sounds like a kind of trivial, superficial statement but that’s precisely the problem.
We’ve got a lot of little systems and a lot of chaotic mix of insurance programs, but there is no national, federal system.
So what every other industrialized country does basically is have a partnership between the government and the private sector. The government sets up the structure and the rules and the standards, and then the private marketplace competes within that structure on the basis of service and outcomes. And that’s the way it can work, and works in many other countries, and it could work here if we’re willing to make some changes.
Lloyd: Well, how do we get there from here? It has been tried, you know, and it didn’t work.
Johnson: Although the “try” early in the Nineties by the Clinton plan was really a semi-disaster. I can remember saying the day I got the plan in my office, 1,342 pages. And I started reading through it, and about a third of the way through, I said, “This is never going to work. It’s way too complicated.” That was part of the problem. It was done in secret; that was part of the problem.
But what the Obama administration, I think, is going to do is to make a really basic try at changing the structure. There are two appointments that I think herald that. One is the appointment of Peter Orszag to the Office of Budget and Management. He’s been the CBO head. Peter is absolutely passionate about health care reform, very knowledgeable about health care costs. When Obama introduced him, he says, “Peter knows where the bodies are buried.” He was referring to Peter’s knowledge of health care, I think.
But the other even probably more significant appointment is that of Tom Daschle as secretary of HHS. He also is passionate about health care reform. He’s written a new book this year called Critical, which is an amazing book. I would recommend anybody who is interested in health care to get that book and read it. And he makes some proposals in that book that are bold and I think right on target.
Lloyd: What’s in that book that excites you? What is he seeing as a possibility of how to put this thing together that seems to you really promising?
Johnson: Well, again, that’s a complicated question, but there are two main features in this book that I think are the most important. The first one is to form a so-called Federal Health Board, which would be like the Federal Reserve Board for the banking system, a group of experts who are appointed, non-political, insulated from the political process.
It’s the only way it’s going to work. They can make the tough decisions separate from all the lobbying that goes on with special interests. As he said, what if the interest rates were set by Congress every quarter? [There would] be sure chaos. Well, that’s what we do with health care. So we’ve got to get the politicians one step removed. The second part is whatever one calls it, an institute of comparative results or outcomes because we have to learn what works and what doesn’t work and pay only for what works. All experts estimate that about a third of the money we spend—a third of $2.5 trillion—is really ineffective in terms of outcomes. We have to have an objective way of deciding what really makes sense and pay only for that, not only to save money but to produce better results.
Lloyd: That’s just another stunning statistic lest we trip right by that: a third of the $2.5 trillion is probably not paying for an incremental benefit.
Johnson: We churn out all the time new drugs, new devices, new procedures, and new tests that are not proven really to be better than what’s already there. They’re proven to be better than placebo. Anything wins against placebo.
But what we need is proof that anything new is better than what we have. We have a technology arms race in health care, really what it comes down to, and so we’re flooded with new technology. We’ve convinced the American public—I’ve done a part of that convincing—that the latest, the newest is automatically the best. It’s just not so. So we’ve got a lot of work to do.
Lloyd: And you sound hopeful that President-Elect Obama is going to be able to move this thing forward.
Johnson: I am hopeful, because he’s talked about it a lot and he’s appointed people who are very knowledgeable and committed. And we’ve got Congress talking about it, again, leading people in Congress: Kennedy, Baucus, and many others. We’ve even got the organizations that have always fought health care reform—insurance companies, business organizations—wanting to be a part of it now. You’ve heard of this disease called mural dyslexia.
Lloyd: Mural dyslexia?
Johnson: The inability to read the handwriting on the wall. (Laughter)
Johnson: That’s what all of these other organizations have done for the last twenty years. They’ve gotten over that. They’ve realized change is coming, so they’re participating.
Lloyd: Apparently even auto manufacturers are now calling for a health care…
Johnson: Here’s a little statistics for you. As we all have heard, we spend at least $1500 per auto worker in health care costs in this country. BMW in Germany, which has an excellent system, pays $450 per worker. That tells you something right there, doesn’t it?
Lloyd: A thousand dollars more per car, basically. Amazing, amazing.
Let’s jump back into your marvelous book, Finding God in the Questions. This book came at a fairly late point in your own career. You were wrapping up what would normally be a full career, pausing to look back and take stock both of your faith and your life and where it’s going. Tell us a little bit about why you decided to write this book at that particular time.
Johnson: I started working on it as I approached my 65th birthday, which is now almost seven years ago. I did it because I have had so many conversations over the years with my secular friends and colleagues in the worlds of both medicine and media. They always knew I was a believer, a minister, and so they would approach me about questions of faith. And I started to realize that they were more or less the same questions and I thought, I should sit down and try to write out some of my thinking about these questions rather than just always respond to them extemporaneously. So that’s really how the book came about.
Lloyd: Now you mention that you were a minister. Everyone might not know that Dr. Tim is also a minister. They might be able to tell it by your gracious demeanor on the screen, but say something about that. How did somebody who was starting off in the ministry find his way into not just to medicine but to broadcasting and journalism medicine?
Johnson: You’re right. I went to seminary thinking that I was going to be a parish minister. In my last year of seminary, I took a course called clinical pastoral education, CPE, that we’ve all taken. I got interested in the world of medicine. Two years later, I went off to medical school, thinking I was going to be a family doctor. That was my dream: small town, like the one I’d grown up in.
I ended up instead in Boston and because of the man who was head of the [Massachusetts] General Hospital, part of the group starting the new ABC station… He asked me to host a little program for them and that’s how I got started in television. It’s just an amazing journey for me, but that’s what happened along the way.
Lloyd: Have you found a sense of integration of the ministerial part of who you are, and the medical part, and the journalist part?
Johnson: I’d like to think that certainly at the heart of being both a minister and a physician is the heart of service at its best. The content of the two is obviously quite different in terms of both what you study and how you practice. But I think the concept of service is integral to both of them.
Now journalism is another story. We’d like to think… And I’ve never described myself, by the way, saying I’m a journalist per se. I’m whatever you want to call it, a commentator, analyst I guess. But mostly, I feel like I’m a doctor who just happened to be on television. And so even when I do my TV work, I have this sense that I’m talking to people as though I would talk to patients in my office, and that’s how I’ve always tried to operate.
Lloyd: You talk about, when you decided to write this book, you had a set of nagging questions yourself about what your own beliefs were. You’ve been a practicing person of faith all of your adult life, but nevertheless there were some questions you thought you needed to go back and take a fresh look at, being the scientist with an analytical mind as well as a person of faith. Were there some particular questions in mind that you really wanted to go back and open up?
Johnson: Well, I was very interested in taking a fresh look at the relationship between science and religion in general, my own scientific background and my own personal faith in particular.
Ever since I was a child, I’ve had this sense that the two are not in conflict. I couldn’t articulate it as a child, but as I became an adult and was privileged to study in both areas I became even more convinced that they are complimentary rather than antagonistic. One of my absolute favorite analogies was offered once by John Polkinghorne. Have you ever had him in the church?
Lloyd: He’s coming soon. He’s coming in a couple of months.
Johnson: A great writer on science and religion. Just magnificent. A British cleric who’s also a particle physicist. And he once offered this little illustration. He said, “Come into my house and there’s a pot of water boiling on the stove and you say, why is that water boiling? And I could answer one of two ways. I could say, ‘Well, there’s heat that’s stirring up the water molecules and they’re rushing around and they reach a boil.’ Or when you ask me why is that water boiling? I could say, ‘Because I wanted a cup of tea.’” Right?
Johnson: Both answers are a hundred percent true, but they’re looking at different questions.
One is answering the question why and the other is answering the question the question how.
In general, I think that’s what happens with science and religion. We’re looking at the same reality but from different points of view and asking different questions. I become increasingly convinced that we see God in both, but it’s using different tools and asking different questions.
The other major question that has always been a tough one for me and I think for most seekers is the question of undeserved suffering. How do we deal with undeserved suffering in this world? We can explain so much suffering by our own bad choices or the bad choices of the collective groups we call “governments,” but cancer in a child? How do we explain that?
I really wrestled with that and I don’t pretend to have an easy answer but what I finally end up saying in the book is that this is a question that I’ve concluded will not get answered in this lifetime for me in a logical, fair way. So I make a leap of faith that somewhere in the future, whatever that will mean for us, we’ll have a better answer but right now we just have to accept it as part of this world.
Lloyd: You make a very interesting move in your book. The first couple of chapters are a beautiful laying out of looking at what science says and how scientific investigation in many ways points to some order and some purpose behind things, that there really is some reality that wants a cup of tea. There is some reality that wants something to happen instead of it just happening.
But then you raise the big question. It’s one thing to say that all the evidence points in that direction; it’s another thing to think we can know that reality. And you begin to ask how it is that we come to know God. Why don’t you say some things about what you investigated and actually how we move from “well, it could be” to “this is God”?
Johnson: Yes. At the end of the scientific investigation, we are left at best, with a creator god that is by definition impersonal. Then all of us in our own way, start looking for other ways in which this god might be revealed. And for Christians of course, the easy and first answer is that we find God revealed in the life of and teachings of Jesus. I believe that to be very, very true and so I spend the whole second section on the book asking who is Jesus and what is Jesus like, and looking at his life and teachings. To me, that ultimately is the answer, a glimpse of what God is like.
In the book, as you know I end up at a certain point, I end up saying that I no longer like to call myself a Christian because that word has lost all precision.
When we talk about a Christian today, are we talking about Al Sharpton or Bishop Spong? They both use that word. They both say they’re Christians. So I call myself now a follower of Jesus, because that drives me back to the Gospel accounts and it says what I’m trying to do, what I’m struggling to do, is to learn about that life and to live accordingly, because that’s where I believe God has most fully revealed himself.
Lloyd: So the word… The cash value of the word “Christian” has deteriorated significantly, you would say. In other words, it means too many things and…
Johnson: Or means nothing.
Lloyd: Or means nothing. And some of the things it means are things you don’t want to mean when you’re describing yourself or your set of convictions. So you’re a follower of Jesus.
Johnson: As were the first disciples. They didn’t call themselves Christians. They just were captivated by the person of Jesus, started following him… And I think obviously in a very different way and a totally different setting that’s what we’re called to do.
Lloyd: What do you find most compelling about Jesus?
Johnson: I guess I would use the word mercy and translate it also into a word that we use a lot, the word grace. I happen to love Philip Yancey’s book, What’s So Amazing About Grace?, one of my all-time favorite books.
Lloyd: Great book, great book.
Johnson: In that book, he defines grace as saying, “grace means there is nothing we can do to make God love us any more or any less.”
And it’s Jesus who taught us that about God. Up until that point, God was thought of as holy, righteous, omnipotent force, but it was Jesus who taught us to think of God as our heavenly father. And that means that we are loved unconditionally. We are loved with mercy and with grace. That’s what I like best.
Lloyd: Have you found on occasion in your life in a largely secular context to find yourself answering questions about your faith, maybe even defending the faith or maybe even finding yourself helping someone out who is in a questioning or searching mode? In other words, has life, as I suspect it has, thrown you into conversations, given this unusual bringing together of being a minister and being in a very secular world as a doctor?
Johnson: Yes, many times, especially in my work at ABC now these many years.
One of the times in ways it happens is that I perform weddings for good friends at work and in my circle of acquaintances. I always insist as part of that process that we talk about faith matters, so that offers an opportunity to do so. But yes, I have people coming up to me all the time and saying either gently and thoughtfully some questions or, “How can you possibly believe that stuff?” in a friendly way.
Johnson: We have some good conversations. I’ve had many wonderful conversations. One of the most interesting—and I say this in the paperback version of the book so it’s public—was with Peter Jennings. Peter and I became very close friends and after I had finished a draft of the book, I asked him to read it. We got together and talked about it.
He said, “Tim, I don’t want you to publish this because people are going to think you’re some kind of a religious nut.” Well, that led to a conversation, as you might expect, and we had a great conversation about faith matters because of that.
Lloyd: It must be something that people are curious about you, certainly among your circle of friends. Are there particular scientific, medical science issues that come up where the faith dimension comes into play? I mean, obviously abortion is one, stem cell research… Have you done any work at that intersection of where faith and medical science are in conversation with each other?
Johnson: Some in both of those areas, but I’m going to pick another one where I think it’s probably the most difficult and poignant area, and that is end-of-life issues.
As part of our techno-consumptive orientation in this society, we have come to want to have, as I said earlier, the latest kinds of treatments and the best kinds of treatments. Very often of course, that comes to bear on the decisions we make at the end of life, where so often we find ourselves, as individuals or families, prolonging death rather than prolonging life. I think that is a point at which our faith should have a very direct bearing because, as people of faith, we supposedly believe that this earthly journey circumscribed by birth and death is not all there is to it. That’s a point at which, if we really believe that, we ought to be able to make some different decisions than we might otherwise. So I find myself talking with people particularly at that moment about these kinds of faith issues.
Lloyd: That’s also an area where, isn’t it, a vast amount of health care dollars are spent in the last, I guess, ten years? Often in the complex drama of how people’s lives come to an end, vast resources are poured in.
Johnson: No question about it. Part of the problem is that we don’t know ahead of time always that it is going to be the last six months. So we get caught up…
Lloyd: There is good reason for that.
Johnson: Good reason for that dilemma, but I’m finding that people are changing their thinking about that.
When I was in medical school back in the last century, the common phrase was, “Do whatever it takes, Doc. I don’t care what it costs.” People don’t say that as much anymore, because they know both that it costs money and, more importantly, that it costs emotion, quality of life, and family time in a way that may not be the most productive.
Lloyd: There’s a good bit of discussion about that I guess in both the medical profession and in the ethics…
Lloyd: Dimension of that…
Johnson: In most major medical centers, they offer departments that will help counsel people and families in those moments and it can be very useful.
Lloyd: Let me ask you one more question and then we’re going to go to our audience, and so if people have a chance to fill out their cards, this would be the moment. Deryl and his helpers are going to collect the cards.
You have a wonderful closing in your book as you talk about Albert Schweitzer, who has been a great hero of yours. Albert Schweitzer, the German scholar, physician, and missionary who spent more than fifty years running medical clinics in West Africa. Having first become one of the world’s great organists and then become one of the world’s great biblical scholars before he went off to Africa after that. He was a big influence on you. Say something about what his impact was and how he grabbed your imagination.
Johnson: Well, growing up as I did in the Forties and Fifties, I was well aware of his life because he was a very prominent media figure in those days, well known to people throughout the world because of his very dramatic renunciation of all of his fame and fortune at age thirty to go to medical school, to go to Africa.
And then very specifically, in college I ended up writing about him for a project and became totally fascinated by his life. Even though I didn’t pursue that interest in any specific ways throughout my lifetime, I have a feeling he was always perched in the back of my head, saying in essence, “Are you living the way you’re supposed to be living?”
His example was a message, a teaching for me.
Later in life in Boston I was privileged, and still am privileged to be involved with the Schweitzer Fellowship Program, which gives fellowships in his name to medical personnel, mostly medical students who work in usually urban settings. So I’ve become now reenergized by his life through that work. I can think of no more dramatic example, in our lifetime at least, of a person who was driven by his own faith—if albeit not an orthodox one at times—to be a follower of Jesus in the most dramatic way possible.
Lloyd: And as you are including in this book, his examples seem to be leaning on you very significantly about what your step would be.
Johnson: Very much so. I think he’d be all for health care reform by the way.
Lloyd: He would be for health care reform? (Laughs) Questions, Deryl?
Deryl Davis: If you would, pass your questions up to the center aisle here as our ushers are coming by to collect them. We’ll start with several that we have here. One of the most problematic questions offered against belief in God has been how can there be a loving God when there is such evil and, more specifically, suffering in the world? How do you answer this as a believer and as a physician?
Johnson: That was a question that Sam asked earlier and as I’ve said, I have struggled with that. I still struggle with it.
Much evil we can explain, but the part we can’t explain is undeserved suffering. I have come to the conclusion that that is something that will not be answered in this life for me satisfactorily. So I make what is clearly a leap of faith by saying, the God that I believe in is a God of justice and love and will not let this matter go unaddressed in the future.
That’s a cop-out for some people. For me, it’s the only way I can handle it.
Davis: Is there any specific model in any countries for the kind of health care reform or the health care system that we need here?
Johnson: There are many excellent models. Let me just take a minute to say that socialized medicine does occur in some other industrialized countries. Britain for example, is true socialized medicine because the government handles both the money side and owns and operates the hospitals and the doctors. That’s true socialized medicine.
Canada is sort of half and half: they do the financing, collect, and disburse the money, but the health care delivery is private. People can pick any doctor and hospital that they want.
We have a system in this country just like that called Medicare. Medicare is basically the Canadian system for people over 65.
One of my favorite models is the German system. Germany is a very large, very capitalistic, very entrepreneurial country, but they have a system where the government, through what they call the joint health committee, sets up the rules and regulations, sets up the charges, and then they have over two hundred—they call them sickness funds—insurance funds that compete for business by offering better service and better outcomes. So you have this wonderful combination of public leadership and private competition that results in a system where everybody is covered—all but .2 percent of the population at a much lower per capita cost and a much lower overall cost.
So I think the German model may be the best for us to look at because that country is probably most similar to us in terms of our overall economic philosophies.
Davis: Why isn’t there more emphasis on preventive medicine? We hear little talk from our politicians about the need for behavioral change: preventing obesity, promoting exercise, and the like.
Johnson: Now I’m going to say something that will just shock you right out of your… I was going to say pews, but I guess that’s… (laughter)
What if we’re so good at prevention that everybody lives to ninety and gets Alzheimer’s Disease?
Now I say that because I’m all for prevention, believe me, as I will now say. But just think the prevention will cut costs but there’s no proof of that. It will cut costs in the short term in some cases, but it’s not necessarily the answer for cost control. If we’re really good at prevention, we’re going to have a lot of people, living a lot longer a lot older and we’re going to have to take care of them in whatever ways.
So prevention is something that makes a lot of sense for all kinds of reasons on an individual case-by-case basis. The real issue right now in terms of health care costs is chronic disease. Seventy-five percent of our health care dollars goes towards the care of people with chronic diseases.
Now if we can prevent people from getting chronic diseases, obviously that would be a big step, but we’re not going to be able to do that a hundred percent or even close to it, so the other big challenge is going to be better coordination of the care of people with chronic diseases: diabetes, heart disease, lung disease… All of these things that require on-going costly care now is usually so scattered and fragmented and therefore more costly and less effective.
Davis: One coming from your own faith experience…
Johnson: By the way, the number one prevention of course is still by far and away is to stop smoking if you do smoke. There’s nothing that even comes close to anything else in prevention than that. Excuse me.
Davis: Coming back to your faith experience, in your experience have you seen what you thought was evidence that faith directly affected healing?
Johnson: Which is sort of a backhanded way of asking do I believe in faith healing, right? That’s probably another way to put that question.
Johnson: As you might imagine, I have thought a lot about that. There is no question that faith leads to healing in many cases. The real question that people are asking usually when they ask that question is, “Does it lead to curing?”
There’s a difference between curing, I think, and healing.
I have seen many people who were ultimately not cured of their disease but were healed in spirit and somewhat in body by their faith.
I have problems with so-called intercessory, or even… especially anonymous, long-distance intercessory prayer. There have been studies that have tried to show that if a group of people is praying for a person they don’t know, that person is likely to do better. But the most recent, best done, multicenter study on that question showed no benefit.
I don’t like that idea both theologically and otherwise. Theologically, it sort of says the more people you’ve got begging on your behalf, the more likely he or she will be to listen to you. I don’t think that’s quite the way it works.
Lloyd: It really turns… It’s a very mechanical notion of God. We’re going to get God all figured out here. We’re going to test this and this and nail God on what God’s up to.
Johnson: Exactly right.
Lloyd: It may be good science. It’s bad religion and science, at the intersection.
Johnson: The data shows clearly that there are many people of no faith who are cured and many people of great faith who are not cured. You just have to say that’s the data.
So I do believe that faith helps us heal. I don’t believe it helps us be cured. That’s my sort of bottom line, simplistic answer to a very complicated question.
Lloyd: Could I just probe in there for a moment, see if I can open a little space for a more traditional view? Could it not be that, while there can be no mechanical connection between who prays or how many pray, might it not be that as we pray, we open up a space in the world, in our relationship with God and our relationship with that person for additional care and concern and healing energy to be directed towards someone else?
I’m a big believer in intercessory prayer because when we pray, I think we are joining our care to God’s own care for this person. And it becomes a communion of love and energy that can possibly have a positive effect.
Johnson: And I have no doubt that prayer in intimate settings—family, congregations, praying for somebody in their midst they know—has an enormous effect on everybody involved. It’s when it’s done in this sort of long distance way that I get nervous.
Davis: Why have hospices remained a misunderstood care option, and how could we better support humane, end of life care options?
Johnson: I’m not sure what this person means by “misunderstood option.” I guess what they’re referring to is the idea that people think that hospice care automatically means “dying care”; and in a sense of course is. Most hospices won’t accept patients unless there is a clear statistical definition of the likelihood of dying within a certain period. But hospice care has proven to be a wonderful alternative for so many people, done both at home and in specific places. So I think it’s much more accepted and much more valued than it was even just ten or twenty years ago. That’s been my experience.
Davis: The concepts of capitalism and medicine seem incongruent to this person as a physician. Could you comment on that? I guess that’s about making money and providing medical services.
Johnson: Well, they are for me, too, in many ways. For example, there are people who propose the free-market answer to controlling medical costs by saying that the informed consumer of medicine, the individual, is the best one to make these decisions.
The problem is, it’s very hard to be a traditional, informed consumer in your own health care, similar to being an informed consumer when you go out to buy a car.
First of all, it’s really hard to get informed, like you can by reading reviews of cars. That’s a pretty simple thing to do. But more importantly, the clear difference is that as a consumer in medicine, you don’t have the ability to say no and walk out the door, do you? Which is what you can do when you’re out buying cars. If you don’t like the price or the service, you can just turn around and walk out.
It’s hard to do when you’re in the emergency room.
Lloyd: It’s a more complex relationship.
Johnson: So I don’t think it’s possible to have a good, informed consumer in the health care arena, and that’s one reason why I don’t think that system works for health care.
But beyond that, I think health care is a right. It is a service. It should not be driven by profit motive at all.
I guess if we thought that way, then why don’t we make fire departments… We could buy fire insurance so we can put out the small fires ourselves. That would be the co-pay, I guess. And then have insurance for the big fires.
You know, there are basic services that are to be provided in the most efficient way possible, and the role of insurance is to spread the risk as widely as possible, meaning the wealthy pay for the poor and the healthy pay for the sick.
That’s what happens in all of these other industrialized countries. They talk about health insurance as social solidarity. We’re all in it together. We share the risk as widely as possible.
Our definition of health insurance has been to charge the most for the people who are the sickest and who have the most difficulty in getting insurance. I was going to say that’s bass ackwards, but I can’t say that, can I? (Laughter)
Lloyd: Well, you just did. But it is a terribly broken system and that is so. We seem to be afraid of a phrase like “social solidarity” in this country, the sense of a commonweal and a common good. For some reason, that scatters people in American body politic.
Davis: Apart from the need for health care reform, what is the single greatest health concern in America and is there any major health concern that has been overlooked?
Johnson: Well, I think the phrase “health care reform” covers a wide area of specific problems, but ultimately that’s the phrase we use to talk about what is the most pressing issue, I think, for this country. In the clinical arena, of course, I could talk about all kinds of individual disease issues, but as I said, I’ve come to the conclusion that the most important thing we have to address right now is not more technology, more devices, more drugs, etc., but a fix of the way we get health care to our population. That will have more impact than any scientific discovery as I’ve said, short of a miracle like the cure for cancer.
Davis: What do you think of the Massachusetts universal health care insurance requirement? Is it working?
Johnson: Sort of. I live in Massachusetts. I know a lot about it. Basically, what Massachusetts has done is set up a system that is pushing for increased coverage, and that is happening.
But what is also then happening, very predictably, is that total health care costs are going up dramatically. That’s why I’m saying unless we also, along with increasing coverage, have structural and systemic changes, all we’re going to do is spread a bad non-system and increase costs.
We’ll get more people covered and that’s good, but we’ll skyrocket the cost and that will ultimately kill us. It’s very much what’s going on with the auto industry right now. I’ve written a little op-ed piece called, “Health care: Reform or Bailout.”
If we simply increase coverage and don’t make structural changes, it’s a bailout. We’ve got to have true reform along with increasing coverage. (Applause)
Davis: This person writes that at the beginning of the conversation today, you made a passing reference to “a miracle like a cure for cancer.” Now you’ve made a second reference. The question here is, is that what it’s going to take? In reference to cancer, we are led to believe that researchers are close to finding a cure. How accurate is that?
Johnson: Well, as you all know, traditionally we have treated cancer secondarily using surgery, radiation, chemotherapy.
In the last twenty to thirty years, we’ve had an explosion of knowledge of what goes on in the cellular level, cell biology, genetics. That’s where we have to be in terms of a cure for cancer, because ultimately, all cancers share one thing in common, which is cell growth out of control. So when we can start to do answers to that question at the cellular level and the genetic level, that’s where we’ll find a cure or cures for cancer. I think we’re getting closer but I still think that’s ten, twenty, thirty years away.
Davis: You’ve talked a good bit about health care costs. This question is directly towards that. What strategy would you recommend as an approach to controlling health care costs for the incoming administration? I guess this is in reference to the universal health care.
Johnson: Well, I would recommend the strategy that Tom Daschle has outlined in his book, which is many things but two key components. First of all, forming the so-called federal health board, which will function as an independent, nonpolitical body, setting policy, making the hard decisions that never expect our politicians to make. And then, as part of that, this institute of comparative outcomes or research, which studies what we do and demands that we prove that something is better than what we already have before we loose it on the public and start paying for it. Let me… we’re out of time?
Lloyd: No, we’re okay.
Johnson: Let me give one example that you’ll all remember and understand, I think. In the Nineties, all of a sudden the use of bone marrow transplants for advanced cancer became a very popular treatment. We’ll all remember that. It was so popular that patients and their doctors started demanding it to the point where if the insurance companies wouldn’t give it, they would sue. And so there were these large suits for huge sums of money against insurance companies. Hundred million dollar suits.
Finally, in the late 1990s, 1999 to be exact, four studies were presented at the cancer meetings that showed that that treatment was no better than the standard advanced chemotherapy.
And literally, almost overnight, we stopped doing it because we finally did the right studies to show whether it worked or not. But in the meantime, we had almost a decade of giving this.
The insurance companies were denying it because it was experimental. Turns out they were right—for the wrong reasons; they were trying to save money—but they were right. That’s what we’ve got to have for all our treatments. We’ve got to have proof of effectiveness, cost effectiveness, and medical effectiveness, and then we’ll start saving some money and we’ll spend it in the right way.
Lloyd: One of the most interesting statistics I’ve come across in the last couple of years has to do with informed patient decision making, that if patients can be given through videos or conversations and counseling a full awareness of the outcomes from the various procedures—which ones actually help and which ones don’t and what are the trade-offs with the negative things that happens in the treatments—they would choose about thirty percent less often with objective data to have the procedure itself which would have a massive saving in the health economy. Thirty percent fewer procedures for just as good an outcome…
Johnson: And that goes back to what we were talking about: so much we spend that really doesn’t contribute to outcomes or effectiveness, and the difficulty in finding that kind of information. I think it’s going to be very hard for an individual to understand all of the information they might have to have but they can certainly be presented it and with help, with nurse practitioners, physician’s assistants, other kinds of help, they can make the right decisions. That’s part of what has to happen.
Lloyd: Right. Is there one more? Is that—?
Davis: One more here. This is about mental health problems and the question here is, why is there so little health insurance that covers things like bipolar disease? Are we as a society treating mental illnesses different from other illnesses in terms of insurance coverage and the like?
Johnson: The answer to the second question is an obvious yes. We are treating them differently and that has to be changed. And fortunately now, that’s under the eye also of health care reform in the new administration. I’m looking forward to some changes there but it’s been a woeful, sad chapter in our health care.
Lloyd: This has been a very encouraging conversation, Tim. I hope you all will come back next week when we’ll be looking at civic life in America, in a conversation with the radio and television talk show host Tavis Smiley.
We hope you’ll stay for the service that begins at 11:15, and meanwhile there’s coffee on at the west end of the cathedral. Dr. Timothy Johnson will be back there to greet you and to sign copies of his wonderful book. Please join me in thanking Tim Johnson for being with us. (Applause)