Healthcare heals the sick. Better pay keeps them healthy in the first place, by James House

The Guardian – Broader insurance access is great, but it’s more effective to prevent people from getting sick – and socioeconomic equality helps do that

We tend to think that access to insurance and medical care is what makes people healthy – but both logic and evidence prove otherwise. The impact of medical intervention on the percentage of sick people in a given population is minor, because people don’t seek it out until they’re already unwell. Healthcare, for the most part, doesn’t prevent illness – it tries to fix it once it happens.

Everyone would be better off if patients’ ailments were prevented or addressed earlier: it would lower the number of sick people and, in turn, reduce medical spending.

Best estimates indicate that doctors, access to hospitals and insurance account for 20 to 30% (and certainly less than half) of how healthy we are. Recent studieshave shown that the Massachusetts reforms of 2006 and an experimental Medicare expansion in Oregon in 2008 did little to either reduce spending or improve physical health.

Despite decades of efforts to make doctors and hospitals more accessible and cost-effective, Americans’ health has only worsened relative to other wealthy nations – and even to some developing ones, I found researching my new book. At the same time, US health spending has grown to almost 20% of GDP, 50 to 100% more than any other nation. While Obamacare has expanded access to insurance (and thus to care), available estimates and evidence indicate that increasing the numbers of insured Americans will only marginally impact either health or health spending.

The answers actually lie in socioeconomic and environmental policies that affect how people live and work, the real drivers of individual and collective well-being. These issues, generally outside the purview of “health policy”, must become central to it, and their impacts on health and healthcare spending should be routinely evaluated.

Social, economic, psychological, behavioral and environmental risk factors for health are quite unequally distributed in America. Disadvantaged socioeconomic groups and racial and ethnic minorities have greater exposure to and experience of almost all risk factors. And these disparities are generally getting larger. For some disadvantaged areas and people, life expectancy is actually declining, something largely without precedent in our – or any – wealthy nation. The greatest opportunity for making Americans healthier lies in improving access to education, income and better occupational and residential conditions.

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Reducing toxic and dangerous environmental exposures, for example, has improved health in hazardous occupations and polluted communities. Policies to reduce cigarette smoking have arguably been the single biggest source of health improvements over the last half century. Both observational and experimental evidence show that policies that increase education and income, from early childhood education to Pell grants to Social Security, improve the health of both children and adults. Better education and income facilitate people having safer and healthier jobs, schools, homes, neighborhoods, behaviors and lifestyles and utilizing more cost-effective health services, such as regular primary care rather than emergency rooms.
Implementing such policies will help our country’s financial bottom line. Healthy people and nations have lower healthcare use and spending; sick people and nations spend more. Credible projections indicate that merely bringing the American people up to the average health level of comparably wealthy European nations would reduce our national health expenditures by over$100bn annually and over $1tn dollars over a decade. This would not just “bend the curve” of health spending, but actually make dollars now spent on healthcare and insurance available for other socially productive and health-promoting purposes. It’s a self-reinforcing solution.

Expanding access to insurance and healthcare is noble and important – and improvements to Obamacare must continue – but it’s time for policymakers to also start following what the evidence tells us: to achieve better health with lower spending, health policy must expand what it includes.

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