January 05, 2007
It's The Economics (As Always)
Garance asks me to comment on this fascinating New York Times article laying out the strong correlations between health and education. She wonders if our health care debate isn't "too focused on questions of coverage and disease treatment, rather than on actually improving the long-term health of the population through public health initiatives whose are results are not immediately apparent."
That's simultaneously true and untrue, but let's bracket it for the moment. The question of whether we could vastly improve health outcomes in this country by forcing everyone into college is an interesting one, but I'm skeptical. Given that no one thinks the dedicated study of Proust unlocks secret immortality enzymes, the question is what education is correlating with to create these outcomes. Most likely, it's a host of factors. On the individual level, less physically taxing jobs, more occupational control, more social capital, less economic stress, more personal power (feelings of control are heavily correlated with good health), etc.
More globally, higher levels of society-wide education will correlate with higher economic growth, a less menial economy, higher incomes, etc. And the article strongly implies that a primary effect of more education is that it makes people smart enough to not smoke, in which case we should pump research into smoking bans (thank you, DC!). And it should be noted that we could make everyone much healthier if we could make them Hispanic.
Those concerns aired, Garance is absolutely right: Our health care debate focuses too much on insurance. Most everyone in this country can access some sort of care, even if only at the point of crisis. That's not an optimal situation, but the available strides in outcomes are fairly limited. The way we pay for coverage simply isn't the primary determinant of health. That said, I wouldn't pull the throttle back on the reform fight by even an inch.
The health care question is more economic than medical -- indeed, it's likely the most important economic problem facing the country. Everyone gets care, but the ambulance ride or cancer diagnosis bankrupts no small number of Americans. That they also lack access to preventive medicine and early diagnostics is deeply troubling. Meanwhile, health care is going to chew up our national economy if we don't get medical inflation under control, and the vagaries of the employer-based health system substantially reduce the freedom of individuals to pursue their own dreams, business ideas, and general bliss while simultaneously bankrupting employers and incentivizing a race to the bottom in benefits.
Indeed, though there are better ways to improve health outcomes than reforming the way our system delivers coverage (like massively funding the NIH), there's nothing that would do more to ensure the economic security and personal freedom of average Americans, or the financial health of the country, than reforming the system. And in the end, it's not an either/or question. A better system would save money, freeing up funds for other public health and social policy priorities.
Also at Tapped
the vagaries of the employer-based health system substantially reduce the freedom of individuals to pursue their own dreams, business ideas, and general bliss
This is another reason (out of a million) that the right is lying about making thindgs better for small business, entreprenuership, etc. The fact remains that a multitude of economy-growing small businesses are NOT created because of the inaccessibility of reasonably priced (i.e. the same as if you worked for a big company) health insurance. I have considered becoming an independent consultant but have been discouraged by the high prices and pre-existing conditions clauses.
Posted by: fasteddie | Jan 5, 2007 5:24:43 PM
- "Most everyone in this country can access some sort of care, even if only at the point of crisis"
- "...the available strides in outcomes are fairly limited"
- "The way we pay for coverage simply isn't the primary determinant of health"
- "Everyone gets care"
I usually like your writing about health care very much... but there are huge, unacknowledged, unwarranted assumptions here.
For the uninsured, the only way to get a modicum of preventive care is at clinics like the one I work at, which are universally understaffed, overcrowded, and funded by scraps from local governments and philanthropists. Care is available, yes, but how can you say the barriers to access don't seriously affect outcomes?
Say we both have chronic high blood pressure and/or diabetes. I have a job-based health plan that lets me see my doctor every few months for a $10 co-pay, and see a cardiologist or an endocrinologist on short notice with a nominal referral. You don't have insurance, but there's a public clinic where you can see your doctor every few months for free... but only if you can wait for two or three hours in a hall full of schizophrenic tweakers... and any consultation or referral will take six months to get, regardless of urgency, because they can only refer to docs at the city hospital.
Do you seriously think that after ten years, there won't be a pretty noticeable difference between your health and mine?
Posted by: Hob | Jan 5, 2007 8:54:59 PM
I am not so sure that massively funding the NIH is a good idea, as the NIH seems to have some problems.
Posted by: Bryce | Jan 5, 2007 9:32:06 PM
be careful, she's a Senior Editor....
and, I'm with Hob in thinking that Most everyone in this country can access some sort of care, even if only at the point of crisis. greatly overstates the reality of who gets what kind of health care if they are uninsured or underinsured. Outside In is not anywhere near the equivalent of Oregon Health and Science University or Providence Portland Medical Center
Posted by: JimPortlandOR | Jan 5, 2007 10:10:33 PM
Emergency room care is universally available. And as wise folks say, the most salient political fact abotu health care in America isn't that 15% lack it (and many of them are youngish, quite a fe children), but that 85% do. There's no doubt that the uninsured get worse care than the insured, but if you want to make great, society-wide strides in health outcomes, public health measures, not insurance, are where you'd start.
Posted by: Ezra | Jan 6, 2007 12:33:01 AM
Ezra, do you think the availability of ER care is at all relevant to the example I gave, or do you think it was just an insignificant or inappropriate example, or what? Hypertension and diabetes are two very common chronic illnesses, and they both have the potential to cause many more woes if they're not managed consistently, and ERs are not at all useful for warding off those woes. You seem to be conflating "preventive care" with primary care in general, but in reality primary care is also necessary for many, many people who are already somewhat sick and need consistent follow-up to avoid becoming a lot sicker; by the time you get to a crisis, your options for getting better are often pretty limited. I'm not just complaining about people getting worse care, as in longer lines or weaker pills or uglier doctors; it's that they get no care when they need it most.
Statements like "The way we pay for coverage simply isn't the primary determinant of health" may be true in some hair-splitting sense, but in situations like I'm talking about, people's options are cruelly constrained by exactly that: the way we pay for coverage. "Emergency room care is universally available", in the context of the current reality, sounds an awful lot like "let them eat cake."
You're right that the system as a whole needs to be overhauled, and that we should look at non-insurance-based options (e.g. the VA, the British system, and the vague plan that San Francisco just voted for - they have criteria for who is eligible for care, and a mechanism for funding it, but they're not insurance plans)... but that's very different from saying that access is somehow a secondary issue. Franke-Ruta, and the Times article she's so impressed with, are just indulging in hand-waving contrarianism.
Posted by: Hob | Jan 6, 2007 2:24:51 AM
So how much does education influence healthy behavior (exercise, diet, etc.)? How much does it affect the attitude and effectiveness of those who administer health care (ability and/or willingness to explain treatments, lifestyle changes, etc.)? Are better-educated patients able to explain their symptoms better, and/or are healthcare providers more likely to listen? Do better-educated patients have a clearer understanding of the benefits and/or risks of treatments? For example, are they more likely to finish their antibiotics instead of stopping as soon as they feel improved?
I don't think you can boil it down to economics, though there are certainly a number of places where economic factors might enter (e.g. proximity to pollutants, access to better foods, etc.).
Posted by: idlemind | Jan 6, 2007 2:47:15 AM
Hob, I'm unsure how much you think you and Ezra disagree about. If I understood him, he said we shouldn't pull back on efforts to cover everyone. I think he agrees with what you say about your examples. But the point remains that, at least arguably, greater good can be done overall by finding better treatments and more efficient means of delivering them to at least the 85%, and often everyone (depending on the type of treatment), than in making sure the 15% (or whatever figure you would accept) has better access to the sometimes insufficient and expensive treatments we already have. If you disagree with that point, you haven't offered any good reason yet. It's consistent with your examples.
Posted by: Sanpete | Jan 6, 2007 4:47:45 AM
No Hob, your example wasn't relevant to what I gave. As I said, care is universally available, though at the point of crisis. That's ER care. I also said preventive and diagnostic suffer. That's what you're talking about. And I lastly said that though changing coverage is a top priority, it's simply not the most important issue for health outcomes. FInd me a researcher who'll disagree with that and I'll be surprised.
Posted by: Ezra | Jan 6, 2007 9:56:42 AM
Posted by: judy | Sep 26, 2007 8:06:13 AM
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