In the last week, we saw the official start of the debate on health reform legislation, after months of speculation on its form. Two pieces of legislation have been released- albeit incomplete, from the Senate’s Health, Education, Labor and Pensions Committee, and the trio of Committees with jurisdiction on the House side. The Senate Finance Committee has delayed the release of its bill until after the July 4 recess; until then we have an outline. (Here’s a chart to help tell the differences).
Conversation continues on how these three bills will converge into one, and form a health policy document that creates real system change. However, no matter the enrollment strategies or financing mechanism used, health reform, even at its best, will not produce a healthier population. Even after ten or 15 years with an improved health care infrastructure in the United States, we are not guaranteed to see dramatic shifts in our health outcomes. What gives?
We are unlikely to see greatly improved outcomes because health is determined by a variety of factors – and medical care is only a small determinant. Actually, good health is based on a variety of factors including income, education, environmental and social conditions, genetics, and lifestyle choices (Grossman 1972; Pappas 1993; Marra and Boland 1995, and many others).
In recent years, a lot of attention has been paid to the social determinants of health (SDOH): education, crime rates, the availability of parks and grocery stores are just a few. The figure below demonstrates how SDOH act as “roots” to cultivate the health of a community by providing pathways to either fragmented systems and restricted power or a sense of community and strong social networks towards health outcomes. The assets determine the pathways and the health outcomes.
The figure above is from, Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health, published by the Centers for Disease Control and Prevention.
Public health researchers are making the connection: for example, we know if you live closer to a grocery store with fresh fruits and veggies, you’re more likely to eat them. Research has shown the difference a single grocery store can make in nutritious eating. With the addition of a grocery store, African Americans were shown to increase fruit and veggie consumption by 32 percent, White Americans by 11 percent. The same trend follows for parks, public transport, etc. Access makes the critical difference.
Research has also long documented “food deserts” – urban areas lacking access to basic food sources. In St. Louis, I experienced this first hand, working with a team at St. Louis University School of Public Health to assess grocery stores in the area. If you live in the northern part of the city, your access to grocery stores with fresh fruits and vegetables, lean meat, and low-fat dairy is significantly limited. However, if you live in St. Louis County (higher income/ less diverse area), grocery stores exist in abundance.
Health disparities follow these trends; in lower access areas, the rates of diabetes, heart disease, and hypertension are all significantly higher, sometimes double. As with most chronic diseases, the highest rates are experienced by minority communities (in St. Louis, African Americans).
In the effort to reform our health care system, the term “shared responsibility” has been used a lot – with the intent that a future “high performing health system” will incorporate wellness and prevention programs to avoid chronic disease. This is the wrong paradigm, borne out of a reactive system of care. Widespread chronic disease prevention requires community-based solutions at the “root” of the problem. What does it matter if someone has access to a wellness program through their insurance but no fresh produce or safe place to exercise? These are the resources that produce a healthier population.
Still, health reform is important in stabilizing the fiscal health of the economy and bringing people in, too long left behind. Perhaps then, we can start to shift our thinking beyond insurance as the cure-all for our ills.
Catherine Morrison, MPH Legislative & Public Affairs Associate
Tags: access, finance committee, food deserts, health care, Health Care Reform, health disparities, Health Value Study, HELP, social determinants of health
I agree with the premise of this blog except for the fact that the current debate on the hill is expressly concerned with the health care delivery system. In this context, most of what has been written in this piece is not applicable to the current debate in government. There are other mechanisms of government that are in place to address these concerns, but to cloud the current debate with these issues would only serve to complicate an already immovable debate. Just my two cents…
I think Mike needs to come up with another 98 cents for a full bucks worth of thought on this issue. Though folks on the hill are broadly concerned with coming up with a delivery system that can get enough votes, that isn’t the entire concept behind health care reform. There are prevention provisions currently being floated and the prevention aspect is what can eventually help any new plan to pay for itself. To say that this is only about the delivery system is to have tunnel vision. By the way, how are those “current mechanisms of government that are in place to address these concerns” working out? Come out from behind YOUR cloud and support a comprehensive approach to health care reform.