Monday, January 26, 2015

Beyond Insurance: Creating the Conditions for Health for Everyone

(I was invited to speak today at a church service and attend a post-service forum about what they could do to make health care more accessible and affordable. I was unable to stay for the forum so I’m not sure what they decided to do. However, I thought you might be interested in some of my comments to the congregation as preparation for their discussion.)

When I was a junior in high school and was debating what career path I should take, I came across the book The Other America by Michael Harrington. The book started with this passage:

“There is a familiar America. It is celebrated in speeches and advertised on television and in magazines. It has the highest mass standard of living the world has ever known… but, there is another America. In it dwells somewhere between 40,000,000 and 50,000,000 citizens of this land. They are poor. … tens of millions of Americans are, at this very moment, maimed in body and spirit, existing at levels beneath those necessary for human decency. … They are without adequate housing and education and medical care.”

It was that book and the picture that it painted about the disparities and inequities that existed in our country that prompted me to choose a career in medicine; thinking that being a physician and working in underserved areas would be an effective way to address those disparities.

Sadly, after more than 40 years as a physician, what was written in 1962 is as accurate and as relevant today as it was then. “There are millions of Americans maimed in body and spirit existing at levels beneath those necessary for human decency, without adequate housing, education, and medical care.”

The persistence of the health problems in our country is certainly not because we haven’t worked on the issues or spent money on them. Despite talking about health reform every year for the last four decades and spending more money on health care than any other country in the world, we are far from the healthiest population on the planet.

Fortunately, I was not the only one affected by Michael Harrington’s book The Other America. It was read by John F. Kennedy and it formed the basis of his social and economic agenda that ultimately led to the Johnson era Great Society programs and the War on Poverty.

I mention that today because it’s exactly 50 years ago this month that the 89th congress was convened, arguably the most productive congress in history. It was a congress that addressed the inequities in our society in ways not seen since then. This is the congress that passed, among other things:

  • Medicare and Medicaid
  • The Voting Rights Act (a year after the Civil Rights Act)
  • Job Corps
  • Peace Corps
  • School lunch program
  • Food stamps
  • Head Start
  • Neighborhood health centers
  • Older Americans Act
  • Elementary & Higher Education Act
  • Housing & Urban Development Act
  • Vocational Rehabilitation Act
  • The Freedom of Information Act
  • Cigarette labeling and advertising act
  • Public Works and Economic Development Act
  • National Foundation on the Arts and the Humanities Act
  • Immigration and Nationality Act
  • Motor Vehicle Air Pollution Control Act
  • Highway Beautification Act
  • National Traffic and Motor Vehicle Safety Act
  • National Historic Preservation Act
  • National Wildlife Refuge System Act
  • Department of Transportation Act
  • many more 
People argue about whether or not the Great Society programs and the War on Poverty worked. From my public health perspective, they were a resounding success. Poverty rates declined, especially for the elderly. We had a more balanced investment in health and social services and what we spent on health care remained in-line with what other developed countries were spending. And our overall health status improved and health disparities were reduced.

The activities that emanated from this national effort reflected what I discovered in my first three months of medical practice – that medical care alone will not make us healthy. I learned quickly that even if I spent every day of my medical career treating dozens of people with diseases, injuries, and disabilities, the overall health of the community would not improve. The unhealthy physical, social, and economic environment in which my patients lived overwhelmed whatever care I could provide. I learned that access to high quality medical care is necessary, but not sufficient, to create a healthy society.

While understanding that medical care is of crucial importance, the policy makers in the 89th congress recognized that it is the policies, systems, and the socioeconomic and physical environments that play the biggest role in determining health. That’s why they not only invested in medical care through Medicare and Medicaid, but also invested in economic development, education, housing, transportation, environmental protection, and a whole lot more. They also empowered communities to become engaged in the decision-making process that developed and implemented programs and initiatives. In addition, they understood that health is not solely under the purview of the health care sector – that every sector is necessary to create a healthy society. In the public health parlance of today, they took a health in all policies approach. They invested in the public good. They invested in the commons. They invested in communities.

We need to learn from that experience because our research now demonstrates the wisdom of that approach in that socioeconomic conditions have been shown to account for more than 50% of our health while medical care contributes about 10%.

We also now know that it’s the disparities in education, income, wealth, housing, and access to a variety of services that lead to health disparities and that those disparities affect the overall health of the community – even those at the top of the socioeconomic ladder. We also recognize that these disparities don’t happen by accident. They are the result of policies that systematically disadvantage some groups, particularly low income populations and people of color and American Indians. That’s why it’s not surprising that the Great Society efforts to improve the health of all Americans were linked with the Civil Rights movement. A socially just society leads to better health for everyone. That’s why the Minnesota Department of Health has made advancing health equity the central focus of our efforts to create a healthier Minnesota.

Unfortunately, the Great Society programs were affected by the Vietnam War which stressed our budget and undermined our trust in government. In the early 1980s a variety of factors led to the dismantling or reduction in support for some of those Great Society programs.

That was also the time when the conversation about what creates health was being systematically recrafted. What emerged was the narrative that health is determined by personal choices and access to medical care. The narrative was that if people simply had health insurance that provided access to high quality health care and they made good choices about diet, exercise, and drug use, they would be healthy.

Looking back, it was at that point that we began to disinvest in the public good and abandoned our community-oriented approach to health and increased our investment in medical care. It was also when our health status (compared to other countries) began to decline, when disparities began to increase, when homelessness and hunger began to reappear, and when our health care costs began to rise astronomically.

That narrative about the primacy of medical care and individual responsibility remains dominant today. It’s that narrative that drives our health policy and it distracts us from what really creates health.

The truth is that health care accounts for only about 10% of our health and personal behaviors account for less than 30% and many of those are often outside the control of the individual. It’s hard to choose healthy food when you are poor and live in a food desert. It’s difficult to be physically active when your neighborhood is unsafe or you are working three jobs just to survive.

Well over 50% of our health is determined by the physical and socioeconomic environment in which we live, learn, work, play, and pray. Despite that, over 95% of our rapidly increasing health expenditures go toward clinical care which obviates the investments in the social and economic conditions necessary to create health for everyone. Without these investments in the community good, which will help prevent the development of disease and disability, the costs of health care will continue to rise.

While it’s important to work for universal access to high quality, culturally appropriate health care, the health of our society cannot be improved solely by those efforts. Certainly, having universal access to a single-payer system would help. But, in fact, our myopic focus solely on health care, health insurance, and medical financing mechanisms, actually interferes with what needs to be done to effectively improve our health. It limits the scope of the needed discussions around health and it limits the discussion to experts in the field of health care. What really is required is the active involvement of all people from all sectors of our society who recognize and understand the broader determinants of health and are willing to work to create a society that is more socially responsible and socially just.

That’s where you come in. As individuals and as a community, you can help change the narrative about what creates health. You can attest to the fact that it’s the policies and systems that create the conditions that support or undermine health. And it’s not just the official health policies that are crucial but the education, housing, transportation, environmental, and economic policies. You can make the case that many in our society don’t have the opportunity to make healthy choices because they are limited by their income, their education, their neighborhood, or their mobility. You can work toward policies that assure a livable wage, paid parental and sick leave, safe and stable housing, effective transportation, incarceration justice, educational achievement, and much more. You can bring an equity lens, a social justice lens, to those conversations recognizing that as Paul Wellstone said, “We all do better, when we all do better.” And you can hold policy makers and public officials like me accountable for the decisions that affect our communities.  

Public health is defined as what we, as a society, do collectively to assure the conditions in which all people can be healthy. That definition doesn't say anything about doctors or nurses or hospitals or clinics. It doesn't even mention health departments. It includes all of us as a society. All of us are responsible for creating the conditions in which people can be healthy. It’s our job, not someone else’s. All of us are part of the collective effort necessary to build a socially just society.

What better place to start that work than here? What better time than now?


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