Don't Forget About The Other Determinants of Health

Nov 12, 2009

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After months of discussion and debate, the House has passed its version of health care reform. But as many observers, including me, have already noted, health care reform has primarily become health insurance reform over the course of the year.

The focus on health insurance reform, at least in part, reflects polling data that shows the public is much more responsive to issues like guaranteeing coverage to people without regard to pre-existing conditions or health status and providing subsidized insurance or access to Medicaid to people who need help. There is far less interest in slowing spending or controlling costs, especially in ways that could be viewed as making access to whatever health care patients or their physicians want more difficult. Not surprisingly, this lesser interest is reflected in the legislation just passed.

To be fair, the House bill, as well as the bill voted out by the Senate Finance Committee, contains a variety of changes that focus on quality and health system performance improvements. These include proposals that encourage the development of more primary care providers as well as requirements to improve the coordination of care for people who are jointly on Medicare and Medicaid and other high users of services.

There are also promising pilots that would bundle payments for post-acute care and that test incentive models that encourage accountable care organizations—groups of providers that are responsible for managing the cost and quality of care for a group of patients--and other payment and service delivery models. Based on past experience, however, the Secretary of Health and Human Services needs to be able to fully implement successful pilots without new authorizing legislation from the Congress. Otherwise the likelihood of even promising pilots becoming a part of Medicare is small.

As we move to the endgame of what will at best be health care reform 1.0, it is also important to remember that if we want to improve health—presumably health care reform is a means to improving health—we need to focus on more than just health care and reform of the health care system.

We probably all know that health care is only one means of improving health. It became especially clear to me after spending three years as a commissioner on the World Health Organization Commission on the Social Determinants of Health, which focused on the relationship of poverty, education, early childhood education, the treatment of women and individual empowerment to health and life expectancy. While the importance of clean water and sanitation to health is obvious for developing countries, focusing on the environment where people live and work is also important for developed countries—especially if we want to make progress reducing the disparities in health outcomes observed in minorities and disadvantaged populations.

The rationale for considering the role of these social determinants of health is relevant for all age groups, but it is especially important for children. Improving the conditions surrounding a child’s early development will improve opportunities for better health throughout the child’s life span. Many of the biggest challenges the country now faces begin in childhood. Obesity, cardiovascular disease, cancer and mental health problems—conditions that account for more than 75% of health care spending today—all can have roots in the early years of life.

Improving nutrition during gestation and delivery is critical to the health development of a child. It also plays a role in the likelihood of a child’s developing obesity, type 2 diabetes, high blood pressure and heart disease later in life. This means that making sure pregnant women with low incomes have stable access to nutritional food is thought of as an important strategy for improving future health.

Making sure that pregnant women have access to substance abuse programs is another strategy that would markedly improve children’s health. As it is, too many children are born with serious medical challenges because their mothers had substance abuse problems. Not aggressively intervening to make sure such care is available and easily accessible imposes large financial burdens on the system and incalculable human costs on the children born to substance-abusing women.

Similarly, investments in early childhood education, especially for the poor, should be regarded as an important tool for preventing disease, improving quality of life and increasing later productivity. Recognizing the social determinants of health means that programs like Head Start, Title I of the Education Act of 1965 that funded schools with high concentrations of poor children and is now part of No Child Left Behind, and ensuring that school lunches provide basic nutrition, including fresh fruits and vegetables, may be as important to improving health as any of the changes now under consideration even if they are not regarded as a traditional part of health care reform.

The Congress and the country are finding reforming the health care system a major challenge—one that is likely to take many rounds of legislation. As we struggle through this first round of health care reform, it is important that we remember that the ultimate goal is to provide for a healthier America. Improving the conditions in which people are born and live, age and die may be at least as important as reforming health care in achieving this goal.

Gail Wilensky is a Senior Fellow at Project HOPE, an international education foundation. She was the Administrator of the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services) from 1990-1992 and the chair of the Medicare Payment Advisory Commission from 1997-2001.