ACA Repeal and the End of Heroic Medicine

By Seán Finan

Last week, I saw Dr Atul Gawande speak at Health Action 2017. Healthcare advocates and activists sat around scribbling notes and clutching at their choice of whole-food, cold-pressed, green and caffeinated morning lifelines. Gawande speaks softly, lyrically and firmly; the perfect bedside manner for healthcare advocates in these early days of the Trump presidency. He calmly announced to the congregation that the age of heroic medicine is over. Fortunately, he continued, that’s a good thing.

Gawande’s remarks echoed a piece he published in the New Yorker. He writes that for thousands of years, humans fought injury, disease and death much like the ant fights the boot. Cures were a heady mixture of quackery, tradition and hope. Survival was largely determined by luck. Medical “emergencies” did not exist; only medical “catastrophes”. However, during the last century, antibiotics and vaccines routed infection, polio and measles. X-rays, MRIs and sophisticated lab tests gave doctors a new depth of understanding. New surgical methods and practices put doctors in a cage match with Death and increasingly, doctors came out with bloody knuckles and a title belt. Gradually, doctors became heroes and miracles became the expectation and the norm. This changed the way we view healthcare. Gawande writes, “it was like discovering that water could put out fire. We built our health-care system, accordingly, to deploy firefighters.”

But the age of heroic medicine is over. Dramatic, emergency interventions are still an important part of the system. However, Gawande insists that the heavy emphasis on flashy, heroic work is misplaced. Much more important is “incremental medicine” and the role of the overworked and underappreciated primary care physician.

Incremental Medicine

Incremental medicine is not the mad dash to the emergency room, but the regular visit to the doctor for a check-up and a tune-up. It is not the violent heart surgery but the recommended dietary changes that stave off the risk of heart disease. When surgeons shrug and look puzzled, it is the decade-long process of monitoring symptoms and adjusting medical regimes, one data point and tweak at time, that brings a chronic condition under control.

The doctor-patient relationship is the key to this. A primary care physician gets to know a patient and their patterns. This brings three major advantages. First, having a good relationship with their primary care physician will encourage patients to go to their doctor more quickly after symptoms appear. A stitch in time saves nine (especially when those stitches are sutures) and early treatment will often lead to better outcomes. Second, regular contact builds trust between the doctor and patient and will often result in better compliance with a prescribed regime. Finally, a longstanding relationship allows for long-term iterating of a treatment plan. The results are not just “better”, but “optimal”.

Snapshots and Trends

Why is this? What does a primary care physician have that a specialist does not? A specialist brings expertise to the appointment but only sees a single point of the patient’s history. A primary care physician gets the data curve. They can see and make decisions based on trends in the patient’s internal systems, their living conditions, the care they have received in the past and their behaviors and idiosyncrasies. None of this eliminates the need for the specialist in dramatic interventions, of course. The most carefully maintained car is still subject to bad conditions, bad driving and all of life’s little accidents. However, regularly checking the oil in the engine and the depth of the tire treads will help keep the car on the road for longer.

The trouble is that checking oil is not glamourous. “Maintaining good health” is not nearly as exciting as “saving lives”. Despite the untold value produced by the steady management of complex health problems, incremental medicine receives the least attention and the least funding. So, when Gawande announces that the age of heroic medicine is over, he is more prophet than historian.

Dangerous Precision

While the structures of the law and medicine catch up, modern technology is helping to turn us all into our own primary care physicians. The birth of the modern Quantified Self movement brought an arsenal of gadgets, gizmos and apps that track everything from sleep to happiness. Some of these devices, like a sleep tracker, allow us to see what might be causing negative health outcomes and suggest what we might do to fix them. Others allow us to correct behavior in real time: Spire is a wearable that monitors your breathing and reminds you to take a moment to reset when you become tense or upset.

All of this is great news for the future of precision medicine. Today’s pill is generic, but it is becoming increasingly clear is that, at least in genetic terms, we actually are unique snowflakes. Our genetics and epigenetics have a profound impact on things as mundane as eating. Instead of following broad, food pyramid style guidelines, or jumping on whatever paleo/all-carb/no-carb/raw/fermented/octo-lacto-vegetarian bandwagon happens to be passing, individuals now have access to a quantified picture of the dictates of their own genes. When asked in a recent interview if he had any specific dietary advice to help navigate the modern mess of contradictory claims, Dr Peter Attia argued that “in an ideal world, everyone would have a [continuous blood glucose monitor] embedded in them…[then, you could] eat whatever you want, [so long as] your average blood glucose remains below 85mg/decilitre and you have a standard deviation below 10mg/decilitre” [at 2.14.25].

However, information is knowledge, knowledge is power and power, if misused, is dangerous. On an individual level, the best tracking equipment is useless if you don’t know how to interpret the data. The potential for an unscientific approach, or a blindness to cognitive fallacies like the confirmation bias, does not bode well for the hypochondriacs among us, much less the obsessives. On a broader level, this Wired article predicts that advances in big data modelling (and artificial intelligence) will allow medical wearables to tell you that you might be sick before you start feeling symptoms. Of course, the dystopian-obsessed pessimist in me wonders just how long it will be before insurers start requiring this kind of information.

“Life is a pre-existing condition”

Which brings us back to the real reason Gawande spoke about heroic and incremental medicine in early 2017. The new administration has promised to repeal and replace the Patient Protection and Affordable Care Act. Specific details about exactly what will be repealed and exactly what a replacement will look like are few and far between. However, both guaranteed issue for patients with a pre-existing condition and mandated coverage for primary and preventive care could be on the chopping block. It is argued that patients should have the right not to pay for coverage that they don’t need. And, if an individual decides that they don’t need coverage at all, they can always get emergency treatment under EMTALA. They can, Gawande counters, but that’s not the point. Pre-existing conditions need sophisticated management, not emergency interventions. This is only possible if patients with pre-existing conditions can get insurance coverage for primary care. The Kaiser Family Foundation estimates that currently, 27% of adult, non-elderly Americans have a pre-existing condition for which they would be denied insurance if the ACA is repealed. One in four Americans is not a small number, but Gawande emphasises that it conceals a larger truth: we all have a chronic disease. We may think we don’t need preventive and primary care, but that’s short sighted. “Life is a pre-existing condition”.

The age of heroic medicine is over. The next stages of incremental medicine hold so much promise. But the threats to the healthcare system have us at a fork in the road. Down one way is a Golden Age of medicine. Down the other, things look a little more Dark.