Reform vs. Transform

By Jonathan Fielding, MD, MPH, MA, MBA

Health insurance reform has been passed. Those of us who feel health care is a right can now see the path to get 95% of the population covered. The evidence is clear: health insurance reform can save lives. But what was missing in the rancorous debate over “health reform” was a sense of context. How important is health care compared with other factors that influence individual and collective health? Are we making investment decisions that flow from the answers to this question? The truth is that health care coverage expansion, albeit overdue and an essential social good, will have a relatively small effect on our relative position of 37th among the nations of the world in life expectancy.

If we want longer, healthier lives, lives with more years of independence and high functioning, we need to complement health insurance reform with more fundamental reform—a transformation of the health enterprise. Transformation requires answering the fundamental question: “What determines our individual and collective health?”

The studies provide a clear but surprising answer. The conditions in which we live, work, and play are the most important health influences. A high school graduate lives on average seven fewer years less than a college graduate. Smoking, other drug use, obesity, inadequate physical activity, and a diet too rich in processed foods are major contributors to our health and functioning—on balance, more important than whether we see a doctor for a routine physical. Medical care is important, and can be life prolonging—but it is only part of the opportunity to minimize most health problems.

This is not fresh news. But there is an almost total disconnect between the fight over “health reform” and what investment would provide the highest value in terms of quality and years of life along with reducing the gaping health disparities among different groups, defined by ethnicity, race, culture, and geography. What we need is a  nation that thinks differently about how we get to be healthy. We must view and act as if health is a necessary characteristic of populations, not just individuals. If we did, we would invest more heavily in evidence-based prevention—both for patients and communities. 

Thinking differently about what determines our health can be transformative. We will ask better questions of ourselves and of those who make policy, both public and private. Thinking differently could cause us to encourage our elected representatives to consider how policies in agriculture, transportation, housing, and social services can support health.

Does subsidization for growing corn, the source of the inexpensive high fructose corn syrup ubiquitously present in foods, improve our health? Does it make sense to have schools with the best local playgrounds declare them off limits to neighbors in their communities? Should almost all our investment in transportation be for roads and highways rather than mass transit and more bikeable, walkable communities? Why should medical care be tax advantaged while we pay after tax for fruits and vegetables or fitness clubs or smoking cessation classes?

The passage of health insurance reform has helped answer the nagging question of access to medical care. Now we have the opportunity—and the imperative—to ask the larger questions about how to improve our health. Shouldn’t the first question be, “If we want to invest cost-effectively to improve health for everyone in our country, what would we do differently—as a nation, as communities, and as individuals?”

Commissioner Jonathan Fielding, MD, MPH, MA, MBA serves as Director of Public Health and Health Officer for Los Angeles County, where he is responsible for the full range of public health activities for 10 million county residents.

Comments

[MargieWeiss]

Great post. The questions posed in paragraph 6 are "right on" in regards to how we develop healthy, sustainable communities. It takes sharing of resources, as well as transformative thinking to integrate environmental infrastructure planning and use, change funding policies and provide support for healthy lifestyles.