I know we all like to think of medical care as “life-saving.” If we just detect disease early enough, and find the right doctors, they will cure whatever ails us. But I would argue that the primary purpose of medicine is not to prevent death. If it were, one would have to judge the entire enterprise an abysmal failure. No one beats death. Granted, some die sooner, others later. Yet as I will explain, health care is not the major factor that leads to longevity.
But I’m getting ahead of myself. Begin with McCardle’s challenge. In the March issue of the Atlantic, she questions the link between health insurance and mortality, noting that we don’t have much hard evidence that Aetna saves lives. She cites a study published in HSR ( Health Services Research, ) by Richard Kronick of the Department of Family and Preventive Medicine at the University of California (San Diego) School of Medicine which adjusted for demographic and health factors to discover that when you make apples to apples comparisons— comparing insured smokers to uninsured smokers, for instance —the rate of mortality was no higher among the uninsured smokers. Kronik later told Politifact.com that he doesn't doubt that individuals' health suffers when they're uninsured — he just hasn't found evidence that they die sooner.
McCardle goes on to explain that she began thinking about the issue in mid-December when Ezra Klein charged that, by threatening to filibuster health reform legislation, Joe Lieberman was demonstrating his willingness to “cause the deaths of hundreds of thousands” of uninsured people in order to punish the progressives who had opposed his reelection in 2006.”
Conservatives rallied around Joe, accusing Klein of a “venomous smear.” Liberals earnestly discussed whether it poisons political discourse to accuse someone of being a mass murderer. To me, the whole brouhaha seemed much ado about a metaphor. At the time, discourse over health care reform had already been polluted, not by figures of speech, but by persistent and deliberate lies. Moreover, given a second or two, I could think of worse things to say about Lieberman—and, in fact, have.
But at the time, I did question Klein’s number. In his response to McCardle last week, Klein acknowledged that it is difficult to nail down hard evidence showing just how many lives are lost for lack of insurance, but studies suggest somewhere between “18,000 and 45,000 unnecessary deaths a year.” He points to “many, many studies assessing the effect of insurance on conditions that kill you, like high blood pressure and cancer. And they show a large protective effect from insurance.”
But I wonder . . . Consider the fact that seventy-three percent of the uninsured are poor, living on incomes that are below 300% of the federal poverty level. Do they die because they don’t have access to medical care, or is poverty the assassin?
We know that, on average, poor Americans die seven years earlier than the rich. A study published in the New England Journal of Medicine in 2004 reveals that low-income Americans are three times as likely to die prematurely as the relatively affluent. Why?
The sheer stress of living below the poverty level taxes both the mind and the body. The poor have far less control over their lives than the rest of us. The threat of violence and unemployment are constant. If you do have a job, you have to wonder: what’s happening to my children after school while I’m at work?
As Dr. Steven Schroeder pointed out in a landmark Shattuck lecture three years ago: When compared to poverty, medical care plays “a relatively minor role” in premature deaths.
The Factors That Determine How Long You Live
I still remember first reading that speech in the New England Journal of Medicine back in 2007. No doubt, Schroeder shocked many as he noted that, in the U.S., lack of access to health care is not the major reason why some of us die sooner than others. Indeed, when he identified five factors which determine how long we live—behavioral patterns, genetic predisposition, social circumstances, environmental exposure and health care—he noted that, “inadequate healthcare accounts for only 10% of premature deaths.” Drawing on studies of actual causes of death in the U.S, Schroeder explained that “Even if the entire U.S. population had access to excellent medical care — which it does not — only a small fraction of these deaths could be prevented. ” By contrast, “behavioral patterns” cause 40 percent of early deaths: In other words, what we do for or to ourselves is far more important than what doctors do for us. “Genetic predisposition” comes next, sealing the fate of 30 percent of Americans who die early. “Social circumstances” follow, explaining 15% of those early deaths while “Environmental Exposure” determines 5%.
Research shows that people who are poor have higher mortality rates for heart disease, diabetes mellitus, high blood pressure, lung cancer, neural tube defects, injuries, and low birth weight, as well as lower survival rates from breast cancer and heart attack.
Is this because they don’t have insurance or because they live in a toxic environment?
Some argue that insurance is the important factor, pointing to studies which show that once they are on Medicare, low-income Americans become healthier. I would suggest that it’s unlikely that a few years on Medicare would reverse the effect of years of poverty. More likely, when you begin to compare adults who make it past 65, you are looking at survivors—the low-income people who will live to 75 or 80, despite their socio-economic status. They come from strong gene pools, and very likely, avoided smoking.
As one researcher points out that, “although it is difficult to separate the effect of lack of access to primary care from that of social and economic status,” it’s worth noting that, “in the United Kingdom, which guarantees universal access to health services, a substantial differential remains in health status outcomes by social class.”
Socio-Economic Status
In the U.K. health experts recognize class differences. In the U.S., Schroeder notes, we tend to avoid talking about class. Indeed a 2009 Institute of Medicine study of people who are uninsured never once mentions poverty as a factor affecting their health.
But the truth is that “people with lower socioeconomic status die earlier and have more disability than those with higher socioeconomic status,” Schroeder observes, “and this pattern holds true in a stepwise fashion from the lowest to the highest classes.” On average, middle-class Americans die sooner than wealthy Americans—even if they have good access to health care. Socio-economic status includes “a combination of income, total wealth, education, employment, and residential neighborhood,” Schroeder explains.
Affluent Americans are more likely to live in a neighborhood where grocery stores carry attractive displays of fresh fruit, vegetables and fish all year round. In poorer neighborhoods, perishable items are more expensive; and stores are not well-stocked because turnover is slow. The wealthy are more likely to belong to a gym. Some can afford trainers, and they have more leisure time to exercise.
Finally, wealthier Americans have more control over their work-place. As Unnatural Causes, an outstanding documentary that explores how Inequality Makes Us Sick reveals: “CEOs tend not to get heart attacks but their subordinates do.”
Are the poor more likely to die of cardiovascular disease because they don’t have good access to medical care—or because they are living on the edge?
Schroeder emphasizes the psycho-social stress that is associated with poverty, and the behaviors that follow. Depression and anxiety lead the poor to self-medicate, using tobacco, alcohol and other drugs. Most adult Americans who still smoke live in low-income households. Much has been written about the correlation between obesity and poverty: low-income children often don’t have gyms or gym teachers in their schools; the playgrounds where they might exercise aren’t safe, and they don’t have easy access to nutritional foods.
Some would blame the poor for obesity, smoking and drug use. If they had insurance, saw a doctor, and followed his advice, wouldn’t this solve their problems? Schroeder notes that aside from bariatric surgery, we don’t have any very effective clinical tools to help the obese. Even if they diet and exercise under medical supervisions, and are entirely compliant, 95% re-gain whatever weight they lose.
Smoking cessation clinics can help smokers, though it’s worth noting that “as many as 200,000 of the 435,000 Americans who die prematurely each year from tobacco-related deaths are people with chronic mental illness, substance-abuse problems, or both.” This doesn’t mean that we shouldn’t try to help them, yet in recent years, we have failed to make an all-out effort—perhaps because so few upper-class and upper-middle class Americans still smoke.
“Merely increasing the baseline quit rate from the current 2.5% of smokers to 10% — a rate seen in placebo groups in most published trials of the new cessation drugs — would prevent 1,170,000 premature deaths,” says Schroeder “No other medical or public health intervention approaches this degree of impact. And we already have the tools to accomplish this.” But instead, we focus all of our attention on trying to make sure that everyone has a piece of paper labeled “health insurance.”
This isn’t to say that insurance isn’t important—just that many more people die because they are addicted to tobacco than because they don’t have a primary care doctor.
Moreover, even when behavior is held constant, people in lower classes are less healthy and die earlier than others. “It is likely,” Schroeder explains, “that the deleterious influence of class on health reflects both absolute and relative material deprivation at the lower end of the spectrum and psychosocial stress along the entire continuum.”
In the end, it is impossible to untangle poverty, lack of insurance, and the many ways that physical illnesses are related to anxiety, anger and despair. We are just beginning to explore the connections between mind and body.
But what I find striking is how many people insist that lack of health insurance is the answer, without even mentioning that most of the uninsured are poor, and that in the U.S. poverty is the prime predictor of an early death.
In part 2 of this post, I’ll review research from the Kaiser Family Foundation which suggests that we are over-estimating the value of medical care on the margin, and argue that universal coverage is important—but not because it saves lives.
I think you’re right on the money. Behavioral patterns are a MAJOR cause of the health care crisis here in the U.S. Health insurance is a tool, not a safety net against proper health and fitness.
Good points. My only comment is that lack of health insurance keeps a person in poverty, or pushes them there, if they get sick and can’t afford to pay the bills. It’s the whole “cycle of poverty” thing, in which “poverty-stricken individuals experience disadvantages as a result of their poverty, which in turn increases their poverty.” (wikipedia)
Nice article, if it was all about saving lives Klein would endorse banning smoking, 55 mph speed limits, and outlawing abortion. Those would have minimal cost and would save over 2 million people a year.
Hi Maggie:
Behavioral patterns are definitely a pattern of health and healthcare. When one is forced into remaining on the lower economic strata due to an inability to achieve upward mobility in America, they are more inclined to eat the unhealthier foods due to cost and availability. It is not there fault there is a lack of upward mobility and in the end the economy pays the price for a lack there-of. Tom Hertz does a nice article called “Undersatnding Mobility In America” http://www.americanprogress.org/kf/hertz_mobility_analysis.pdf
Great post Maggie
One good thing for Insurance? How much money have you spent for them and how long have you been their customer.
I wouldn’t be so quick as to rule out direct links between insurance status and mortality.
Yes of course the overall socioeconomic picture is complex, and in any case we need to widen the definition of healthcare to include public health, prevention, health promotion and comprehensive primary care, rather than just a narrow focus on acute care.
But there is plenty of evidence that uninsured and underinsured people forego check-ups, do not buy all their prescribed drugs and actually fail to secure any first line standard treatment for diseases such as cancer and certainly not in a timely manner.
There is good material on the American Cancer Society site.
http://www.cancer.org/docroot/subsite/accesstocare/content/Articles_and_Information.asp
As the ACS president says:
‘Virtually any clinician who treats people with cancer in the United States knows of patients who presented with advanced cancer that should have been found early, but was not. For many of these patients, cost of care and lack of access to care were the primary barriers to earlier diagnosis. This problem is not confined to Americans who have no health insurance. It impacts patients who have types of insurance that are not accepted by providers due to low reimbursement rates, those with insurance who cannot afford copayments or whose policies do not cover needed services, and is a unique barrier to those who are already burdened with medical debt. We all remember patients who died prematurely (despite expensive treatment) because they received care only sporadically in emergency departments, had no primary care provider to help with tobacco cessation or other preventive care, or because their insurance status precluded receiving the usual standard of oncology care once they were diagnosed.’
“inadequate healthcare accounts for only 10% of premature deaths”
That’s inadequate health care, not inadequate health insurance. There’s plenty of inadequate or incompetent health care provided to well-insured people.
Marc Brown’s point about expanding the definition of healthcare to include public health, prevention, health promotion and comprehensive primary care
misses the point that most public health, health promotion and disease prevention doesn’t require health insurance.
‘Marc Brown’s point about expanding the definition of healthcare to include public health, prevention, health promotion and comprehensive primary care misses the point that most public health, health promotion and disease prevention doesn’t require health insurance.’
Well, in countries such as the UK national insurance and income tax are not hypothecated to hospitals or clinics, so the government can provide broader services, although the UK NHS does itself provide services such as smoking cessation.
And there’s plenty of evidence to show that the US should be investing in health promotion, for example:
‘Government health promotion and prevention programs for pre-Medicare and Medicare populations could save the country as much as $1.4 trillion over 10 years—and add on average as many as 6 years on Medicare beneficiaries’ lives, according to a new Center for Health Research at Healthways report.’
http://healthplans.hcpro.com/content/HEP-236758/Prevention-and-Health-Promotion-Could-Save-Medicare-14-Trillion-Over-10-Years
Good comments Maggie. Also worth recognizing is the work of David R. Williams, PhD, of the Altarum Institute. Below is one of his blog postings:
“Health Is Not Just About Health Care” (6/15/09)
The Robert Wood Johnson Foundation Commission to Build a Healthier America, of which I have served as staff director, recently released its report with 10 recommendations that we believe will allow Americans – particularly those who face the greatest barriers to good health – to lead healthy lives. The recommendations are rooted in a twin philosophy: Building a healthier America requires individuals to make healthy choices for themselves and their families and a societal commitment to remove the obstacles preventing too many Americans from making healthy choices.
So often, our nation’s health care debate seems to focus on providing health insurance coverage to those who currently have none. Without a doubt, this is a very pressing need, as those without health insurance often do not have access to adequate preventative care. Worse still, when the uninsured do need health care, they often face crushing personal costs or simply cannot pay at all, resulting in significant harm to themselves or cost shifts to others.
As important as health insurance coverage is, however, it is only one piece of the health care challenge. I believe that giving health insurance to every person in the United States would actually contribute only a little to improving most people’s health. Health insurance helps us get medical care when we’re sick. But medical care accounts for only about 10–20 percent of preventable deaths. If we want to live longer, healthier lives, we need to focus on factors that keep us from getting sick in the first place.
Good health is not just about having good doctors and good hospitals. It’s about having a good education and good child care when you’re very young. It’s about living in safe, clean neighborhoods where your kids can play outside and where you can buy groceries for your family. It’s having a decent home to live in and being able to raise your kids to be healthy and happy.
When you come right down to it, health is mostly about where we live, learn, work, and play. These are the places that shape our everyday health, and they are tied to powerful social factors like income and education.
These social factors can work for us or against us. For example, if you live in a safe, clean neighborhood with parks and sidewalks and supermarkets that sell plenty of fresh produce, it’s easier to be healthy than if you live in an area where there is a lot of crime; where there are no parks or sidewalks; and where, instead of grocery stores, you have little more than fast-food restaurants and liquor stores.
Let’s face it: It’s hard to eat right if there’s no grocery store nearby. You’re not going for a jog after work if you’re afraid for your safety or do not understand the importance of fitness and exercise. And it’s difficult to manage your child’s asthma if you live in a building that’s infested with roaches.
The current health reform debate in Washington has not focused on these factors, but the Commission to Build a Healthier America has. The Commission’s recommendations provide us with a blueprint for how this nation can improve health. Unlike the frequent debates about health care coverage or costs, our report focuses on the solutions available in our schools, our homes, our neighborhoods, and our workplaces. We hope the policy making community in Washington will make use of this blueprint.
Where people live, learn, work, and play affects how long and how well they live to a greater extent than most of us realize. For the first time in our history, the United States is raising a generation of children who may live sicker and shorter lives than their parents. Reversing this trend will depend on healthy decisions by each of us, but not everyone in America has the same opportunities to make healthy choices. In many instances, barriers to good health decisions are too high for an individual to overcome. The Commission focused on the places where we spend the bulk of our time – homes and communities, schools and workplaces – in order to identify where people should make healthier choices and where society should remove the obstacles preventing too many American’s from making healthy decisions.
Health is not just health care. We need to broaden our view of health and factor health into all aspects of everyday life and decision making – from education and child care to community planning to business practices. We’ve done it with the environment by “going green” – why can’t we do it with health? An increasingly unhealthy nation is counting on us to do so.
To learn more about the work and recommendations of the Robert Wood Johnson Commission to Build a Healthier America, please visit http://www.commissiononhealth.org.
Insightful thoughts Maggie. This is another classic case of poorly interpreted statistical data.
Nice article and nice question too!I know this is not what you want to say.cool you are right insurance can not save the life.New health program announce by Mr.Obama is not so cool for citizen.
This is right on, Maggie, but it makes me wonder why you spend so much of your time discussing a health care insurance reform proposal that, even if it passes, based on the evidence you cite here, we have no reason to suspect will substantially improve population health or compress inequities.
This is not to deny the normative claim in expanding access to sick care services, but to question, as you do here, the move from the ethical paradigm to the counterfactual proposition that doing so is likely to improve population health.
But if that move is unjustified, as I believe, doesn’t that compel us to assess why it is even the so-called experts spend so much powder and shot on debating a set of policies which the evidence definitively suggests are unlikely to improve health, reduce suffering, and ameliorate inequities?
Hi everyone–
Thank you for your comments.
I’ve been travelling all week, back Sat. night–
will catch up with replies then.
JMS, Daniel, Isaac, Marc Brown & Marc Stone ( a reply to you both)
Jms—
Good to hear from you. And thank you for the quote from Williams.
Williams writes: “So often, our nation’s health care debate seems to focus on providing health insurance coverage to those who currently have none. Without a doubt, this is a very pressing need, as those without health insurance often do not have access to adequate preventative care. Worse still, when the uninsured do need health care, they often face crushing personal costs or simply cannot pay at all, resulting in significant harm to themselves or cost shifts to others.
“As important as health insurance coverage is, however, it is only one piece of the health care challenge. I believe that giving health insurance to every person in the United States would actually contribute only a little to improving most people’s health. Health insurance helps us get medical care when we’re sick. But medical care accounts for only about 10–20 percent of preventable deaths. If we want to live longer, healthier lives, we need to focus on factors that keep us from getting sick in the first place.
“Good health is not just about having good doctors and good hospitals. It’s about having a good education and good child care when you’re very young. It’s about living in safe, clean neighborhoods where your kids can play outside and where you can buy groceries for your family. It’s having a decent home to live in and being able to raise your kids to be healthy and happy.
“When you come right down to it, health is mostly about where we live, learn, work, and play. These are the places that shape our everyday health, and they are tied to powerful social factors like income and education.”
Yes, exactly, and very well put.
It is not that good health insurance that provides access to care isn’t important. It is. It can reduce much needless suffering (see part 2 of my post)
But, it’s only one piece of the health care problem. Public health (improving housing, the environment, education providing places to exercise, access to healthy food) is at least as important—and more important if we are talking about preventing premature mortalities.
When it comes to death, and dying earlier, Poverty is the big killer, not lack of access to healthcare.
And, as you say, The current health reform debate in Washington has not focused on these factors (the importance of education, housing etc. to improve public health) , but the Commission to Build a Healthier America has.
I’d urge everyone to look at the website http://www.commissiononhealth.org
Daniel—
Welcome to the comments section. (I don’t recognize your name as a commenter, so I’m assuming you may be a new reader, or perhaps, a silent reader.)
Poverty is the main cause of premature death. And you are entirely right—politicians should spend more powder and shot on public health.
But I’m not saying that good insurance wouldn’t help the uninsured –it could spare them a great deal of needless suffering. The poor child with an ear-ache who doesn’t get to a doctor to get a pain-killer, the 60-year-old who really needs a knee transplant, but without insurance cannot possible afford it and so is home-bound . (See part 2 of the post)
At the same time having insurance and access to health care is not that likely to save their lives because
A) in this country, when poor people are critically ill, most often , at that point they DO get health care, and if the illness is curable, they are “saved” –and sent back to their life of poverty. And
B) B: poverty is the leading cause of premature death and having health insurance doesn’t solve the problems that makes poverty a killer.
The truth is that in the U.S., so many people die prematurely not because they don’t get health care but because they are poor. Poor people die 7 years earlier than the rich. Even with good insurance and access to care they still would probably die, on average,6 or 7 years sooner than the rich s because they are exposed to polluted environments from childhood (toxic dumps near their neighborhoods, housing and public schools infested with cockroaches and mice; neighborhoods infested with rats, plus the constant danger of violence (“environment” contributes to 15% of premature deaths) and “behaviors” which contribute to 40% of premature deaths (smoking, alcoholism, drugs and obesity, all highly correlated with poverty for reasons I explain.)
Give an impoverished, unemployed person who lives with constant stress health insurance and he/or she is not likely to stop drinking excessively unless his/her life changes in a way that makes him/her more hopeful about life.
But insurance is important to prevent much needless suffering. With the insurance, the poor might not live longer, but their lives would not be quite as difficult. Imagine what it would mean to be able to take your 3-year-old who is crying all night with an ear-ache to a doctor, or a 55-year-old to get the knee transplant she really needs.
Even very imperfect universal coverage would help the poor.
Isaac—
Welcome to the post, and thank you.
Yes, too often people don’t want to wade through the data and final discussion of what it means.
Marc Brown & Marc Stone
First I agree—universal health insurance won’t give us public health programs. The two are funded separately. And, if we want to save lives and prevent premature deaths, we need much better public health programs, at least as much as we need universal coverage.
But public health programs also don’t give us universal coverage. Public health initiatives wouldn’t ensure that the 60-year old low-income person who needs n artificial knee so that she won’t be house-bound would get one.
(Preventive medical care would not insure that she wouldn’t need the knee transplant at 60. If she is a low-income worker, who spent most of her life on her feet (say, as a waitress), her knees are likely to wear out at a fairly early age—particularly if she is heavy (which is likely if she grew up poor.) . Genes also play a major role in this sort of thing. Even if people have access to good health care, eat right, and try to take care of themselves, some people will age faster than others, some will have trouble seeing, others will have trouble hearing., some will find that their knees go . . .