Have we lost sight of the overall goal of health care reform -- improving people's health -- by focusing too narrowly on coverage? That's a question I found myself asking last week while attending the Grantmakers in Health annual meeting on health philanthropy in Orlando (where the weather was as cold and dreary as back home in New York).
The closing speaker was Dr. Christopher Murray, a physician and health economist based in Washington State, who showed us slide after slide on the geographic variation in health outcomes and mortality within the United States. He pointed out that, although the United States as a whole ranks about 36th in the world in life expectancy, in many counties across the country, the average life expectancy is equal to that in China or Iraq -- countries in the middle or bottom of the list.
New research supported by the Robert Wood Johnson Foundation, which ranked the overall health of every county in New York (and in all 50 states), also bears this out. For example, 27% of people in the Bronx are in poor or fair health, while in Putnam County it's only 9%.
Murray argued that expanding health insurance is one way to improve health outcomes and reduce mortality, and the national health reform discussion has focused on expanding health insurance coverage and reining in health care costs. But even universal coverage wouldn't eliminate disparities entirely or get our nation's overall life expectancy much closer to Japan's (which was number one on the list), because our health is about more than just the care we receive.
How healthy we are also has to do with whether we smoke, what we eat, and how much we exercise. For example, expanding insurance coverage to everyone in the United States would save between 20,000 and 40,000 lives per year, but ending obesity would save 216,000 lives annually.
While we must take responsibility for our own health, it's not just about the choices we make as individuals. Policy choices also play a major role, from whether healthy, affordable food options are available in our neighborhoods, to whether we have safe places to walk, play, and exercise in our communities. When we tackle those issues, we will see a significant increase in the health of all of our communities, and fewer disparities across counties.
Here in New York, could public/private partnerships to bring supermarkets to underserved areas improve the health of families who have limited access to affordable, nutritious foods, as it has in Pennsylvania?
Could the proposed soda tax reduce New Yorkers' consumption of high-calorie, low-nutrient beverages, just as tobacco taxes and smoke-free indoor air policies have reduced tobacco use?
Would investments in complete streets policies (which ensure that our roads work not just for drivers, but also for pedestrians and bicyclists) improve our health and wellbeing by allowing us to move more -- and more safely -- in cities and towns throughout the State?
Could enforcement of school wellness policies ensure that all kids get nutritious foods and ample opportunities for physical activity during the day?
I would argue that the answer to all of these questions is yes, and that these types of State- and community-level interventions could help to improve the health of all New Yorkers, particularly those who now are struggling the most.
So have we lost our focus on improving people's health by focusing on coverage? If we stop pursuing broader reforms to improve health once the federal health care bill passes, then yes. But if solving the coverage problem federally allows states to focus on other aspects of improving health, then we've been on the right path all along.
Follow James R. Knickman on Twitter: www.twitter.com/jimknickman
This is all a start- In HCR checkups and wellness visits are included- I hope that alternative treatments will be in HCR- it saves money and produces results-
EMTs with good ALS will get you there. So that HAS to be supported.
Let alone how to pay for insurance.
Maybe NO caps on Medicare, count in bonuses / stock options for CEOs. Stock trades for individuals that are providing income over say $60k a year adjusted for inflation will count as regular income for tax and Medicare purposes.
Catastrophic care , say cancer, care over $30k is automatically covered at 100%. Now audit the heck out of this.
And we need to reduce costs. No more $128 pacifiers. Which are discarded when they fall on the floor. $5 aspirin, $thousands for implants, go through the list.
There is too much emphasis on malpractice VERDICTS. We need to get rid of the BAD DOCTORS. Put them on a national death panel, lose a license in one state, you're gone forever. There's too much boys will be boys with a wink and a nod as far as license revocations. And if you're on alcohol / drug rehab, you're not practicing or seeing patients. Let alone surgery.
I suspect that coverage controversy resonates more with the general public than the effort needed to move more and sit/eat less - or the dry details of delivery reform where there is a concensus - see the six priority areas of the National Priorities Partnership convened by the National Quality Forum (at http://www.nationalprioritiespartnership.org/). More importantly, these initiatives will provide the savings to pay for coverage expansion -- If implemented prior to coverage reform, there would not be sufficient savings left for CBO to favorably score coverage expansion alone.
The challenge is to effectively use tools like geographic differences to answer questions WHY localities like Bronx and Putnam counties differ so markedly. Is it differences in patient needs versus waste versus how best to achieve necessary lifestyle changes in areas with diverse cultures or simply the relative availability of healthy food and safe places to walk and play? Perhaps all of the above?
I wholeheartedly agree - the real benefit is in improving people's health. I'm optimistic that both delivery and lifestyle reforms can and will continue after coverage reform. I can't wait to focus on HOW to reform our healthcare system rather than if. - John Shaw, President, Next Wave, Albany, NY
I remember a Scientific American article from a few years ago... By controlling for all kinds of variables, some scientists determined that the biggest predictor of health-stratification within a nation is created by relative poverty in the society. This is even up against the variables of national healthcare and cleanliness of water... The culprit is the stress that relative poverty creates (not living up to social expectations, unable to work way up to socially expected outcomes, able to see the contrast in the situations of the well-off).
This shouldn't be shocking because stress is known to cause over 80% of serious ailments in Americans.
But I don't expect there is much of a movement we can expect to tackle stress as a public health issue. The only party I know of who does is Natural Law... and frankly I think they're nuts.
But, yeah, there are lots of things we need to work on with health care. It's just hard to get political momentum behind some of them. Coverage can be framed as a public concern. So far, people still consider personal health a personal issue, ignoring the social costs and the social causes.