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More than four and a half years after passage of the Affordable Care Act (ACA), the primary political remedies offered to improve the health of disadvantaged Americans remain focused narrowly on financing more health insurance coverage. ACA advocates urge still-skeptical state governments to expand eligibility for Medicaid coverage with supposedly “free” federal dollars. Most would-be conservative health policy reformers do not oppose spending more money on the poor per se. But they want to do it differently, by giving states greater discretion to provide subsidized private insurance to more Medicaid-eligible beneficiaries. Unfortunately, offering slight variations of “more of the same” in covered health services also is likely to deliver more of the same in disappointing health outcomes and continued health disparities.
Health policy compassion toward the poor needs to be measured more accurately by the changes it achieves in long-term health outputs than by the increases in short-term health services inputs it funds. Finding more productive paths to improved health will require capitalizing on persuasive research findings, retargeting resources, and breaking old habits.
The key starting point involves the remarkably limited influence of different levels of medical care quality and access on mortality reduction and disease burden. It accounts for roughly 10 percent to 20 percent of the determinants of health. Genetic factors may be more significant (20 percent to 30 percent), but they are by definition far less malleable. On the other hand, health behavior related to modifiable risk factors (primarily smoking, diet, and physical activity) has a larger impact of about 40 percent. Those factors, in turn, are shaped and augmented by a broader set of social determinants of health, such as education levels, family structure, physical environment, and early childhood development.
Of course, none of these estimates are precise, and their definitional boundaries overlap at the margins. They do not deny the importance of medical care in treating acute emergencies, later-stage illnesses, and disabling conditions. However, we will always remain behind a very expensive health care cost curve if health policy continues to focus predominantly on directing resources to fix (or patch up) at the last minute whatever ultimately shows up as broken in our inevitably unhealthy bodies.
Intervening earlier to prevent or delay the development of more costly, chronic health conditions as we mature as adults would slow the pace and reduce the volume of demands we ultimately will make on a highly sophisticated, but expensive, health care treatment system. Recent research links problems in prenatal and early childhood experience (particularly stress-related adverse events, poor nutrition, and limited parental involvement) to an increased likelihood of chronic health conditions later in life as well as deficits in the cognitive skills and personality traits needed to manage them as adults.
If we truly are interested in improving the overall health of those most likely to fall behind, and not just boosting the financial health of the health care sector, some significant rebalancing of our time and effort would appear to be in order. But moving from the theoretical to the practical will entail building on some smaller initial steps, assessing difficult tradeoffs, overcoming longstanding policy biases, and avoiding new versions of old pitfalls.
The most significant hurdle involves changing our time perspective in assessing the value of health-enhancing interventions. The human temptation to yield to the therapeutic imperative of trying to do “something” right away in response to visible illnesses (whether or not it works well) may preempt commitments of time and resources to other approaches that do not “pay off” immediately but have longer-lasting effects. Our political system further aggravates this bias toward favoring the most visible short-term inputs in health policy. Time horizons of many officeholders don’t usually extend beyond the next election cycle, budgetary scoring windows penalize pay-now/save-later strategies, and the most organized health care interests are those receiving reimbursements for services with a billing code.
However, some of the most effective forms of “primary” prevention do not even involve conventional medical services like screening tests and visits to a doctor’s office. They often begin with healthy and caring parents, living in safe neighborhoods, who instill important values and traits in their children well before they receive formal schooling. Guaranteeing idyllic home environments for every modern family is unrealistic, but public policies that encourage and support more stable families (such as expanded economic opportunities, better access to good nutrition, more effective school systems, safer streets, and revitalized communities) may do more to improve the odds for the long-term health of poorer Americans than the next thin layer of publicly subsidized insurance coverage accomplishes.
The issue is essentially one of rebalancing limited resources and changing relative areas of emphasis on the margin, rather than finding any single cure-all solution. The history of recent health policy is full of political food fights over who gets paid how much to deliver a wide array of increasingly sophisticated medical services, and then how to hide the size and share of the bill that we respectively pay for them. Yet as the political commitments to comprehensive health insurance coverage increase through formula-based legal entitlements, we lose sight of other public and private investments in individual well-being and long-term health that they crowd out.
Reversing our narrow focus on health services financing that over-medicates more complex economic and social problems faces two further challenges: How to get started and how to avoid recreating old policy biases in new programmatic wrappers.
We should resist the urge to nationalize a new set of standardized interventions that adopt “Got a problem; got a program; get some political credit” shortcuts. Successful examples along the less-beaten path develop at the community and (sometimes) state levels. They are less likely to scale-up successfully unless they allow ample room for variation, innovation, and customization.
Nor should we fall for the old trick of repackaging today’s health care services as tomorrow’s new innovations under a slightly reformatted set of insurance reimbursement codes. Evidence of improved outputs must trump marketing creativity that merely rearranges old inputs.
Overpromising and over treating were both the causes and effects of our current bloated health care budgets. Let’s move more slowly but decisively in reexamining how to produce better health, instead of just higher health care bills. Although the most promising opportunities involve the youngest Americans, we still have to manage the care of the substantial “installed base” of older individuals with more advanced illnesses and chronic conditions more effectively as well (another challenging topic for a later discussion…). Even the best types of early interventions, primary prevention tools, and improved decision making skills suffer from the law of diminishing returns in older populations.
A host of uncertainties and ambiguities remain over exactly what we should measure and assess before upsetting the status quo. But policy paralysis through over-analysis of terminology is not progress. We already have a pretty good idea about what does not work well even for well-insured Americans, and what remains particularly inadequate for vulnerable individuals suffering from fractured family structures, economic distress, and social neglect. So the initial generic prescription is to get started in newer rounds of patient-centered trial and error, by at least loosening more of the standardized insurance coverage strings around current budgetary commitments to poorer Americans enrolled in Medicaid or the ACA’s new health insurance exchanges. By providing them with greater choice and control over how to improve their own health, and the opportunity to receive wider varieties of community-based counseling and coordination, we might start to learn that they want something better and how they can find it.
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