By: Casey Means, MD and Grady Means
Healthcare in America is going through a revolution
With the explosion of lifestyle-related medical conditions including obesity, diabetes, cardiovascular disease, and cancer, some in the medical community are shifting their focus to evidence-based prevention and care, with recommendations for diet, exercise, supplements, detoxification, and stress management. Within this new paradigm, using food as medicine has become central to effective medical treatment.
Extensive medical research has clearly shown how consumption of meat, dairy, sugar, refined grains, processed vegetable oils, and sodium has a significant detrimental impact on health. It is becoming increasingly clear that shifting away from these disease-promoting foods toward a whole-foods, plant-based diet could save the American health care system hundreds of billions of dollars a year, make Americans much healthier, improve overall economic productivity, and have a substantial impact on helping the environment.
Slow, but consistent, changes in consumer attitudes are emerging, with demands for more organic and plant-based products, but a real health revolution is still very slow to come. This is especially frustrating to leading health care providers and medical researchers who can see the massive potential in a more rapid change in American diet and lifestyle.
All of this raises a fundamental question: If support for excellent American health, lower health care costs, improved productivity, arrest of the opioid crisis, and environmental protection are central responsibilities of government, how can public policy be reshaped to achieve those goals, based upon the clear evidence supporting whole-foods, plant-based diets? The critical question is: how do we create real political leverage leading to a revolution in food, diet, and health outcomes and costs?
This is a very complicated question, and it is important to examine the complex web of entrenched economic interests, the narrow perspective of a majority of the health care community, and the self-defeating economic incentives framing health care delivery, in order to understand the root-causes preventing real progress.
To begin with, let’s examine some of the major social and public policy drivers that lead to poor food choices and related health issues:
Social preferences and traditional attitudes that lead to consumer demands for specific foods
The physiologically addictive power of sugar, salt, dairy and other food substances
Political and cultural importance of the meat, dairy, sugar, grain, salt, and processed food industries
A segmented health care sector with an economic structure that drives a reactive “name it and treat it” approach
A health care finance system that is fee-for-service rather than fee-for-health
A majority of doctors who have virtually no clinically useful training in nutrition and prevention
The Politics of Food
Since the founding of America, the agriculture industry has expanded into a massive enterprise to supply meat, dairy products, sugar, grains, and salt to the US and much of the world. It is a trillion dollar a year business, employing 22 million people, and representing nearly 6% of GNP (Gross National Product) and 11% of all US jobs. (1) A central and unchanging tenet of national security policy is food independence and security, largely based on those food categories. (2) The economies and identities of many U.S. States can be defined by their beef, pork, chicken, grain, and dairy industries. Thus, it is little wonder that the industry is supported and protected by a vast array of laws and government programs, defended by large and very well-funded lobbying, “education,” and “interest” groups, and the best law firms in the country.
An array of government programs support the supply-side of agricultural products that are found increasingly to be disease promoting.
Public programs support the price of milk and cheese, and the government buys eggs and cheese in huge quantities to, in turn, be placed in food banks and distributed to food programs for low-income individuals, or exported through foreign aid programs. (3,4,5,6,7,8) Beef and other livestock are supported through a complex array of subsidized public land grazing programs as well as huge “disaster relief” grants. (9,10) Livestock are also supported through a variety of loan programs. (11) There are multi-billion dollar subsidies to support corn and feed grains (an indirect subsidy to the meat industry), cotton, soybeans, wheat, tobacco, dairy, rice, and peanuts. (12) Loan programs are also available on these commodities. Even the US sugar industry is supported by a price support program. (13,14) Overall farm pricing and economics are stabilized by commodity exchanges, regulated by the Federal Commodity Futures Trading Commission. (15)
On the demand side, the $70 billion SNAP program (the Supplemental Nutrition Assistance Program, formerly Food Stamps) provides funds to 40 million low income Americans for food security. With few restrictions on food choices, much of those funds predictably go to traditional grocery products, including sweetened drinks, milk, candy, sugar, cereal, meat, and bread. (16,17,18) A related program, WIC (the Women, Infants, and Children nutrition program), provides $7 billion in food support (largely concentrated on processed infant food, meat, dairy, cereal, bread, juice, and formula) to low income young mothers and infants under 5 years old. (19) Finally, there are a variety of domestic and international food aid distribution programs through which the USDA (US Department of Agriculture), the Department of Defense, and the State Department purchase US food and distribute food to disadvantaged people or disaster relief efforts. (20)
In terms of food guidance, the myPyramid, promoted by the USDA, continues to concentrate a large portion of the diet on meat, dairy, and refined grain products.
At the local level, school boards and administrators continue to focus on school lunch and cafeteria menus loaded with fat, sugar, salt, dairy, and processed grains. Studies suggest the vast majority of calories offered in school meals come from solid fats and added sugars. (21) A continuing, extremely dark irony is that hospital dining options are generally not much better. (22)
Given this overview of the ways in which government programs and policy influence food and, ultimately, food choices, the question becomes, what can the medical community do to guide public policy toward healthier, plant-based diets?
First, it is our opinion that waging a direct assault on the meat, dairy, sugar, grain, and processed food industries will not work. This would involve facing an army of hundreds of powerful lobby groups, strong local political and economic interests, and embedded consumer tastes, and will take a very long time to create meaningful change. The power and resources of these industries are vast and they are very experienced in political warfare. In addition, the impact to the US economy of a rapid change in these industries would be catastrophic.
Second, the government cannot tell consumers what foods they can consume. Cigarettes are still widely sold. Mike Bloomberg’s ban on “Big Gulp” sodas in New York City was ruled unconstitutional. (23)
A third strategy would be to restrict unhealthy foods in various public programs. New York’s experiment with “meatless Mondays” in public schools may show some promise. (24) On the other hand, restrictions on sodas in public schools did not curb consumption of other sugar sweetened drinks and had marginal impact. (25) Both the Physicians Committee for Responsible Medicine and the excellent report from the Bipartisan Policy Center, “Leading with Nutrition: Leveraging Federal Programs for Better Health” (chaired by two former Secretaries of Agriculture - Ann Veneman and Dan Glickman — and former Senate Majority Leader, Bill Frist, MD) suggest restricting SNAP funds from sugar sweetened drinks. (26) These ideas, along with other broader policy and research proposals in the report, point to growing political attention to the issue. But, given what the scientific community knows about the diet-related epidemics of obesity, diabetes, cancer, and cardiovascular disease, these still seem like marginal attacks on a huge medical, social, and economic problem.
A fourth strategy would be to promote shifts in American attitudes towards foods through education and marketing. Attitudes and consumer tastes are already changing, with increased demand for plant-based products and organic foods, and even large national fast food chains offering salads and plant-based burgers. (27) The public demands will continue to lead to political and industry change, as these industries are likely to follow the money. Even the meat industry is subtly re-branding itself as a “protein industry.” (28) But, again, these moves are slow when faced with an epidemic and rapidly rising health care costs.
Changing the World: Structural Change in Health Care Policy and Economics to Support Plant-Based Health and Disease Reversal — “The Patients/ Patience Paradigm”
With these trends and political realities in mind, we think it might be a good time for the plant- based health movement to pivot to an even more effective political strategy that can be wielded right now to reform the diet and health of Americans: health care policy reform. While health-driven agricultural policy reform is not a strong political issue currently, health care finance and delivery reform is. In fact, it will probably be the biggest political issue over the next couple of years.
We believe the food-based health community can play a key role in this debate by arguing that a major “root cause” of why we aren’t making progress in getting Americans truly healthier is the financial structure of current health care delivery.
The health care system in America faces a number of systemic problems that the political process has not been able to solve:
It pays largely for sick-care rather than health-promotion: it is fee-for-service rather than fee-for-health
It has been impossible to restrain cost increases, and price transparency in healthcare is poor (29)
Billing systems have narrowed the autonomy of practitioners and demoralized medical care professionals with time consuming bureaucracy and administration (30)
The results of the National Health Insurance Experiment suggest that a single payer system, built on the back of a CMS (Centers for Medicare and Medicaid Services) fee-for- service system, will further drive cost inflation and exacerbate the pressure on medical care providers, as well as lead to rationing of care (31)
All of this leads to a system with the financial incentives and medical care style focused on “treatment” rather than “health,” and thus defeats reforms in diet and lifestyle.
The central and unique problem in the health care “industry,” which represents 18% of the US economy, is that it is the only American industrial sector that separates the finance of services (health insurance) from the delivery of healthcare services into two distinct industries with vastly different economic drivers and consumer/market expectations.
Other industries can respond to market forces to make service, pricing, investment and human resources decisions in a way that drives quality, innovation, and cost control. Health care does not. In healthcare, non-market forces decide upon reimbursable treatments and the amount of the reimbursement (i.e., DRGs - Diagnosis Related Groups), fixating the system around service reimbursement rather than health. (32) Additionally, to maximize reimbursements, the current system requires a vast amount of costly administrative support, sets and reduces reimbursement levels arbitrarily, adds patients without a proportional increase in health care professionals, and thus squeezes doctors to see increasing numbers of patients in shorter periods of time. The only healthcare industry model that has been advanced thus far to deal with these issues and effectively integrate finance and delivery is the managed- care/managed-competition model (i.e., capitated HMO-style — Health Maintenance Organization — groups). These systems rely on generating value, which could be defined as health outcomes divided by cost. And, importantly, it is this model that puts the most focus on wellness, diet, and lifestyle.
It is our opinion that a truly effective revolution to improve quality, control costs, and shift the focus to healthcare (rather than sick-care) would involve the creation of a true market system of 8-10 large, nationally competitive, managed care institutions, vertically integrated with finance, healthcare providers, and healthcare facilities. These would eliminate traditional fee-for service insurance systems in favor of capitated systems, which naturally incentivize cost-saving and wellness.
In the past, capitated systems have led to fears about care quality and rationing within some HMOs. Most of these organizations were small and under-capitalized and lacked the financial capacity to take on full fiduciary responsibility for patients, and thus create effective health care management systems, and failed. However, if current industry consolidation and public policy combined to create a set of large and effective managed care companies, and patients had the real option to choose from a variety of these organizations, market forces would drive these organizations to provide the best, most competitive care, at the lowest cost.
Let’s say we’re dealing with heart disease. In a capitated system where finance and delivery are coupled, a costly cardiac catheterization, ICU (Intensive Care Unit) stay, and a lifelong prescription for costly drugs would seem less attractive than getting a patient to eat healthily and manage stress (which can reverse coronary artery disease). (33) Intensive cardiac lifestyle interventions, which include a plant-based diet, have been shown to save up to $17,687 per patient over a three year period compared to conventional care. (34) In a fee-for-service model, however, the invasive treatment option is a cash cow, and is favored, despite having worse outcomes than diet and lifestyle interventions.
To some degree, there is some movement in this direction through industry consolidation and mergers, leading to larger, integrated healthcare systems, but they still rely on the fee-for-service, fee-reimbursement approach which defeats market pressure for better cost control and quality. It is time for the private sector to understand that one of the biggest business opportunities in history is unfolding in health industry consolidation around a health-based model.
The bureaucratic approach pushed forward by the ACA (Affordable Care Act or “Obama-care”) does little to fix this problem through APMs, ACOs, QPP, and MIPS (Alternative Payment Methods, Accountable Care Organizations, Quality Payment Program, Merit-based Incentive Payment System). They continue to rely on agreements with government agencies to set and measure targets.
In the “value/cost” equation, they tend to focus on the denominator (cutting costs), much more than the numerator (sustained health). ACOs, for example, work to achieve efficiencies and “quality” mainly through reducing duplicated services, rather than a true focus on wellness. What these programs have done is achieve minor efficiencies through small consolidations of health care delivery. The problem is that a true, long-term commitment to patient health requires large scale (billions in capital and tens of millions in patients) to support the fiduciary responsibilities in adopting a health- focused delivery model which has the systems and resources to deliver wellness-focused services over a sustained period of time.
Under-capitalized HMOs have failed because lack of sufficient resources has led to scrimping on patient care to meet budgets. On the other hand, as with Kaiser, successful managed care/managed competition groups must be large and national in scale. (In contrast, the fee-for-service model does not require scale, but cannot deliver the wellness focus.) In short, true health care reform requires patients (a lot of them) and patience (the scale to support long-term solutions). “Medicare for All” creates the illusion that it can take the ACA experiments to a large scale though government payments leading to consolidation. (35) The problem is that it would not use market forces to allocate resources and properly manage and compensate providers. It would dictate both compensation and delivery approaches (possibly including food choices), all of which would be rejected over time by providers and consumers leading to a system collapse, and a return to a private sector, two-tiered system. The bottom line is this: if plant-based diet and lifestyle changes are to become central to medical care delivery in the near future, it requires a fundamental change in public policy to create a new medical care finance and delivery system focused on health.
Fortunately, appropriate finance and delivery models exist and now is the time to aggressively push for them politically if public policy is to be harnessed effectively to focus on American health.
A Revolutionary Plan for American Health Care Focused on Sustained Health
A health-based, plant-driven revolution in American health care is a very big idea and it requires an effective political strategy to get there. The American medical care system has been living on a fee-for-service diet and it is now sick; a complete lifestyle change is needed for the system to heal itself. The most effective push for the medical community dedicated to plant-based medical solutions would be a combination of public policy proposals and private sector communication that would lead to a large, health focused, managed care market. The specifics are beyond the scope of this paper, but would likely involve:
Continued industry consolidation along the lines of very large, national, managed care groups that would abandon fee-for-service and assume responsibility for patient health — i.e., physicians focused on plant-based care and health should be actively communicating and shaping the future visions and strategies of the largest health insurance and health care groups, as well as their investment banks, to achieve large-scale change
Selected changes in tax policies
CMS restructuring to drastically reduce regulation and administrative burden on physicians and hospital systems, and support very large, capitated systems
Elimination of state-by-state insurance regulation which defeats scale and fragments delivery in favor of national oversight
Tort reform to reduce unnecessary and expensive tests and procedures of “defensive medicine” and allow a focus on long-term health
The payoff for American health, the health care system, the reformed food industry, the environment, and the American economy is gigantic. And with 350 million patients and their physicians looking to optimize the value (health outcomes/cost) of their healthcare, this would, organically, lead back to the highest value interventions: healthy eating and lifestyle changes.
We have roughly estimated these healthcare proposals could save the US economy a minimum of $200 billion per year in reduced cost related to declines in chronic conditions including obesity, cardiovascular disease, and diabetes. As important, it could represent the largest private-sector transformation and investment opportunity of all time.
This model may also naturally trickle back to medical education, as it would be important to effectively train health care providers in the highest value interventions, which are nutrition, lifestyle interventions, and prevention. If healthcare policy allowed for market forces to truly function, the entire medical community might begin to line up behind better nutrition and better health in order to optimize value and competitiveness.
To sum up: Changing the economics of health care delivery, which, in turn, changes physician attitudes towards treatment and nutrition, would lead to much quicker changes in consumer food choices, and, in turn, the food industry, all represent a strong platform for an American health revolution.
Now is the time to push for this style of health care revolution. Medicare-for-All would only compound the current mess and take the country even more deeply into a CMS-controlled fee-for- service sick-care system. (35) Physicians focused on dramatically improving American health must take the lead on this.
As in our medical approach to disease reversal in individual patients, our discussion about fixing the health of Americans at large through plant-
based eating must focus on the root-causes of our dysfunction. While the agriculture industry, food policy, and food programs are clearly involved culprits, these are inopportune and inefficient targets in our current political and cultural climate. The better root-cause target is health policy and the financing of health care, which, paradoxically will lead us to exactly where we want Americans to be: the produce aisle.
Dr. Casey Means (www.caseymeansmd.com) received her MD from the Stanford University School of Medicine and was an ENT surgical resident before starting her Functional Medicine practice in Portland, Oregon. She writes about “Food As Medicine” on Instagram @drcaseyskitchen.
Grady Means (www.gradymeans.com) is a retired business executive who served at the U.S. Department of Health, Education, and Welfare, helping draft and implement the HMO Act of 1973, and in the White House overseeing the Food and Nutrition Task Force to reform Food Stamps and White House liaison to the National Health Insurance Experiment.