The Social Determinants of Health

05/25/2011 12:30 pm ET

This morning, let's consider the case of Fay Derricote, an obese, 44-year-old former government contract worker confined to a wheelchair with multiple sclerosis. For the first time in her life, she has good health insurance -- provided by Medicare because she is disabled.

That's precisely what her former employer, the food service firm that ran a government cafeteria in the nation's capital, didn't provide her while she was working, according to this morning's Wall Street Journal. "How Government Adds To Ranks of Uninsured: Many Outsourced Federal Jobs Don't Offer Health Insurance," the headline read.

Sadly, the story's focus on a federal subcontractor contributes to the unenlightened anti-government bias that muddies public debate in this country. How is government outsourcing of jobs to contract firms that fail to provide health insurance any different than the Fortune 500 firms that do the same thing? The 47 million uninsured Americans -- most of whom work for a living -- aren't all employed by government subcontractors. The reporter could just as easily have made the same point using the janitorial services that clean the privately-owned office buildings that house Washington's thousands of private sector lobbyists.

Still, every element of Derricote's case sheds light on the health insurance debate. Unlike most private sector subcontractors, the law requires government subcontractors to make a payment in lieu of insurance so workers can buy their own policies. In her case, that would have come to an extra $3.16 an hour on top of the $7 an hour she earned as a cashier. But a loophole in the law exempts employers in industries that don't typically provide insurance.

Now she has wonderful insurance, courtesy of the very same government that didn't require her employer to insure her. Had she been treated two years earlier, according to her doctor, he might have been able to slow the progression of her disease and gotten her back in the workforce.

It's outrageous, of course, that her lack of insurance delayed care and contributed to the growing disparities in health that, according to this new chart book from the Commonwealth Fund, have worsened in recent years. If we're going to have an employer-based system of providing health insurance in the U.S., doesn't it make sense to require all jobs either provide that benefit or pay into a government fund that becomes the default insurer (the Democratic approach)?

The idea of putting money in people's paycheck so they can buy insurance as individuals or families (the Republican approach) makes no sense for low-income people like Derricote. As the story pointed out, when employers use that approach, most low-wage workers use the money to pay rent, buy food or meet other day-to-day necessities. What would you do if you earned $14,500 a year?

But the story, and the debate over health insurance that marks the two sides in the presidential campaign, did not address the most significant element in her story. What were the social factors that led this relatively young woman to balloon to 289 pounds before a doctor at her place of employment -- the Department of Health and Human Services! -- warned her to go on a diet before she got really sick. His mere warning led her to lose 55 pounds, but it was too late.

Would adequate health insurance have prevented her weight gain? Would the policy have paid for counseling? Would insurance have relieved the stress and time pressures in a life lived earning $7 an hour that contributes to poor dietary habits? Would it have made a dinner that included unsubsidized fish and broccoli less expensive than a trip to McDonald's, where the costs of the red meat, bread, and sugar are kept artificially low through farm subsidy programs? Would it have made her a more informed consumer by putting calorie counts on the menu choices at restaurants or the cafeteria where she worked, where she presumably ate at least one meal a day? Would it have required her employer to give her time during the day to visit the gym, or money to pay for a membership?

Insurance is an important starting point for the national discussion about health. Access to health care is crucial. But unless the nation simultaneously grapples with what are the underlying causes of ill-health in this society, it will never get health care costs under control.

The who and why of the modern day plagues of obesity, high blood pressure, smoking and alcoholism are the undiscussed elephants in the room. These disease precursors are the primary causes of heart disease, diabetes, and most cancers, and their prevalence is closely correlated with inequality, poverty, race, and stress. The chronic diseases that result from these conditions only affect about 30 percent of the population, but they lead to 70 percent of all health care expenditures in the U.S.

The presidential candidates, and everyone running for Congress this year should watch Unnatural Causes, which kicks off on Thursday this week on most PBS stations. There's still hope that the national discussion about health insurance can be expanded to include the more important discussion about the social determinants of ill-health, the primary reason why our nation lags behind most other industrialized nations in overall life expectancy.

Originally published