Public Health Versus Health Care Financing

One frustrating aspect of the American health care debate is that policy arguments center almost entirely on ways to change the health care financing system, when all the evidence suggests that the provision of health care isn't actually a very effective way of improving health outcomes. Which isn't to say that health care finance isn't an important issue; it's hugely important to people's finances and somewhat important to their actual health. It would, however, make a ton of sense to find time to focus more attention on more effective sorts of public health measures than helping sick people go to the doctor.

Mark Kleiman has more on this and here's Phillip Longman's classic article on the subject.

Comments

Making this an either/or question is the surest way to ensure that neither happens. People need to eat healthier, but that has as much to do with the cost of healthy foods as it does with poor eating habits. Lack of exercise is mostly about Americans being overworked, not about them being lazy. Improving access to health care is thus a more realistic step, as it only requires a universal health care bill. While difficult, it would be a lot easier than trying to pass the 5-10 bills required to make a healthier lifestyle more accessible to most Americans.

Posted by soullite | May 27, 2007 12:11 PM

"all the evidence suggests that the provision of health care isn't actually a very effective way of improving health outcomes."

Gack. I think there's an overwhelming amount of evidence that the American health care financing system is the major impediment to raising American health care outcomes to first world standards.

Posted by Petey | May 27, 2007 12:33 PM

Yes, but....in America, things happen when somebody makes or loses money thereby.

Twenty-five years ago I gave a talk to a nursing school public health class, saying that improvements in industrial safety, air pollution, and other preventative measures would really only come after the advent of universal care made obvious the dollar savings.

When I returned to my seat, my buddy leaned over and said "They didn't understand a word you were saying".

Apparently they didn't.

Posted by serial catowner | May 27, 2007 1:40 PM

"It would, however, make a ton of sense to find time to focus more attention on more effective sorts of public health measures than helping sick people go to the doctor."

To expand only slightly, if sick people were able to go to the doctor as part of rational reform of the American health care financing system, many of the perverse monetary incentives that keep the health care system from creating better health outcomes would disappear.

Or put in reverse, as long as the current American health care financing system remains in place, those perverse monetary incentives will make dramatic improvement in health care outcomes essentially impossible.

In short, if you want more effective sorts of public health measures, the first task on the to do list is helping sick people go to the doctor.

Posted by Petey | May 27, 2007 1:45 PM

Note for Petey and Soullite-

Health care outcomes fall in the "what happened next" category. IOW, it is much better never to have had diabetes than to have had it and lost.

Huge amounts of our poor health come from a suburban lifestyle. Of course people are tired, when you add an hours commute to the nine hours they work to pay for the car and home in the suburbs. But it's the danger in riding a bicycle on suburban roads and the lack of a daily walk to a store for fresh locally grown vegetables that puts you in the danger zone for diabetes, heart disease, and stroke.

Making it easier to see a doctor who will tell you this won't make much difference in outcomes.

Secondly, social isolation and distance are major factors making interventions late, costly, and ineffective. To put it simply, if an older person gets out every day to shop or visit a community center, they will be missed if they don't appear, and someone will check on them.

During the great Chicago heatwave (a decade ago?) it was found that most of the people who died were people who didn't get out every day. They simply weren't missed until it was too late. A different example is that almost everyone asks a friend or relative about their health problem before deciding to see a doctor, obviously more cost-effective than consulting the drug advertisements on the telly. When it comes to heart attacks, the major cause of death is waiting too long to seek help.

Yes, it will be hard to redevelop our society on a sustainable basis. But if we don't, we'll fry the planet like a peanut. We've got lots of incentive.

Posted by serial catowner | May 27, 2007 2:01 PM

"Yes, it will be hard to redevelop our society on a sustainable basis. But if we don't, we'll fry the planet like a peanut."

Thanks for the update from hippie-ville.

Personally, I'd be happy with the more modest goal of reforming the health care financing system so the perverse monetary incentives that keep the health care system from creating better health outcomes would disappear.

That'd get us up to first world standards, at which point the updates from hippie-ville would actually become relevant.

Posted by Petey | May 27, 2007 2:13 PM

Look at today's news. Specifically Gina Kolata's piece in today's Times on the abysmal state of stroke care in America.

You have to get 75% of the way through the story before you get to the key sentence:

Stroke patients, unlike heart attack patients, are not moneymakers. Because of the way medical care is reimbursed, most hospitals either lose money or do little more than break even with stroke care...

Moving beyond strokes, when you start looking into monetary incentives throughout the American health care financing system, on both small and large scales, you tend to find that the incentives rarely lead in the direction of good health care outcomes.

The American disadvantage is true when you compare our incentives to the incentives in public systems like Canada and Britain, and also true when you compare them to the incentives in public/private hybrids like France and Japan.

Posted by Petey | May 27, 2007 2:33 PM

Well, right back atya, Petey. Your conspiracy theory of "perverse incentives" is the equivalent of saying driving costs you a lot of money because you don't trust your auto mechanic.

In reality, of course, it's the cost of the vehicle, the cost of the fuel, and the opportunity costs of applying your skilled mind to a task that most illiterates can do, that is the major expense of driving.

When it comes to American healthcare, the biggest grassy knoll is right where you'd expect to find it- in suburbia. The doctors are not shadowy "third shooters" in this conspiracy.

Posted by serial catowner | May 27, 2007 2:43 PM

"Well, right back atya, Petey. Your conspiracy theory of "perverse incentives" is the equivalent of saying driving costs you a lot of money because you don't trust your auto mechanic."

Actually, an analogy that actually fits, (since yours doesn't), and one that happily works with your obsession would be this one:

The transportation funding and mortgage tax systems are why we are a suburban nation. We have cheap gasoline. We fund highways, but not mass transit. We subsidize home ownership over apartment renting.

As long as those fiscal incentives are in place, they will create a tremendous incentive toward suburban living.

Similarly, the current health care financing system creates a multitude of perverse monetary incentives that keep the health care system from having the capability of creating better health outcomes.

-----

"The doctors are not shadowy "third shooters" in this conspiracy."

And where the fuck did I ever blame it on doctors?

Why respond to what I write if you aren't going to even bother with reading it?

Posted by Petey | May 27, 2007 2:55 PM

What Petey is missing, or trying to distract us from, about Matt's post is that the post related to health outcomes.

Health outcomes overwhelmingly come from actions that are not part of institutionalized medicine. See Longman's excellent article.

When we consider the societal actions that cause bad health, and the extent to which we subsidize them, we can make major changes without touching the medical billing practices.

Disallow advertising as a deductible "business expense". How can it really be necessary to advertise alcohol, which people will seek on the black market if you make it illegal? In no way can this advertising be regarded as a legitimate expense that should be shielded from taxation.

Cutting away the thickets of subsidies and bogus deductions could really be regarded as a safari to the rumored but never seen land of Free Markets. Stop taking land off the tax rolls to build roads that compete with land the railroads pay taxes on. Assess the real downstream cost to the hog factories of America. Stop the dumping of garbage into the atmosphere or tax it heavily to reflect the real costs to society.

Of course, the major corporations have no desire at all to see a really Free Market. Fifty years ago my dad explained to me that while the corporations shed tears about regulations they were actually packing the regulatory agencies with their own guys to keep competitors out.

And that's part of why American companies make 40-mpg cars abroad, but you can't buy them here, because of "safety regulations".

None of this has anything to do with the business of healthcare, but it has much to do with health outcomes- you know, the results money can't buy, if you spend your money on a doctor.

Posted by serial catowner | May 27, 2007 3:06 PM

Well, that's the way it goes, Petey. Some days I just feel like replying in kind when someone uses words like "hippie-ville" or "obsession".

Especially when someone like Phillip Longman has already done all the heavy lifting.

Posted by serial catowner | May 27, 2007 3:15 PM

"Health outcomes overwhelmingly come from actions that are not part of institutionalized medicine. See Longman's excellent article."

I've read Longman's article. You don't seem clear or informed on the topics at hand, or even the particulars directly discussed. And since, most crucially, you don't seem capable of basic reading comprehension, I will simply give up, lacking a reader.

"Fifty years ago my dad explained to me that while..."

And if we had a better functioning health care system, perhaps the onset of your senility could have been stopped or delayed.

Posted by Petey | May 27, 2007 3:21 PM

"Well, that's the way it goes, Petey. Some days I just feel like replying in kind when someone uses words like "hippie-ville" or "obsession"."

But what about on days when no one uses words like that, and you still don't have a clue as to what is being discussed.

Just the way it goes, I suppose...

And seriously, resounding in kind or not, how did you manage to intuit that I was blaming things on doctors, or that I was positing a conspiracy?

Maybe I'll be senile a few decades down the road, and I'd love to know what the thought process is like.

Posted by Petey | May 27, 2007 3:30 PM

I find myself mildly horrified at the speed at which this conversation went downhill.

Posted by Neil the Ethical Werewolf | May 27, 2007 4:12 PM

It is of course correct that lifestyle has a lot of impact on various conditions that form the backbone of health costs. However, it's also correct (as Petey points out) that actual legislation to fix lifestyle incentives is hugely complex and crosses a number of different policy eras.

People like Kleiman and Longman underestimate the costs of changing lifestyles. You can purchase better nutritional education as a "public good" but it will cost plenty.

Most importantly, whilst that kind of spending can make today's children healthier when they reach retirement, there remains a huge running sore of societal inequality in the treatment that current retirees get.

Not to mention that the current system results in horrendous difficulties for some in society when the get small injuries. Just watch the Morgan Spurlock 30 days where he lives on minimum wage to see what effect the current system has on people who need treatment but don't have insurance.

Posted by Meh | May 27, 2007 4:38 PM

As do I. Although, having spent a working lifetime in the industry, it's hard not to just laugh at Petey's approach.

Still, I wonder if Petey can offer any specific in which I differ materially from Longman's appreciation. I would certainly like to know what that is if any exist.

However, I have a dim memory of asking Petey for specifics when he engaged in a series of ad hominem attacks on Don Williams, and getting no specifics in return.

When Petey refers vaguely (and I use that term advisedly, having re-read his comments) to "perverse incentives", the most reasonable assumption, given the lack of any other explanation being offered, is that he is referring to the fact that the system is largely paid to treat problems rather than preventing them. "Perverse incentives" masquerades as a value-free descriptive phrase, but stumbles on the inclusion of the word "perverse", which, as we all know, is very bad indeed. It's not hard to see that Petey thinks there is a sort of conspiracy by somebody to control all the loot.

But there is no "perverse incentive" that prevents you from eating an apple a day or exercising for half an hour!

At least, not in the field of medicine.

Posted by serial catowner | May 27, 2007 4:50 PM

Yes, but the good thing about that hugely complex legislation is that much of it can be of local origin.

We could, if we wanted to, make the local school campus a 24/7 center of the community, with clinics, social centers and dining facilities, community college and technical training, low income and mixed use housing development, pools and playfields, all in walkable distance of one another, reducing the cost of each individual effort and maximizing the use we get from each building. And this could all be done by local authorities using existing financing and powers.

Will it really be easier to hammer out Draconian laws and major funding initiatives on the federal level, reaching into each city and hamlet with new directives, to make it possible for people to walk or bike to work?

I personally doubt it, but only time will tell.

Posted by serial catowner | May 27, 2007 4:58 PM

People focus on the health care financing system because it's full of perverse incentives that encourage waste and inefficiency. That's why the U.S. spends far more per capital on health care than other western democracies, but in return gets health outcomes that at best are no better.

Posted by kafka | May 27, 2007 6:55 PM

Migawd, it's like the attack of the perverse incentives robots.

Who so totally miss the point- our health outcomes are mainly the result of a lot of things we do entirely outside the healthcare industry.

'Nuff said.

Posted by serial catowner | May 27, 2007 7:33 PM

Re: When it comes to American healthcare, the biggest grassy knoll is right where you'd expect to find it- in suburbia.

Oh, good grief. The people who live in the suburbs and exurbs, especially the upper middle class sorts, are actually quite healthy. Has something to do with having enough money to eat properly and engage in healthy activities (bikes, skis etc. are expensive toys you know) Also, they have decent to excellent healthcare. It's the folks in the downsacle neighborhoods, notably in the cities, but also in rural areas, who have the worst healthcare problems.

Posted by JonF | May 28, 2007 12:24 AM

Good grief is right. The notion that suburbanites have poor health because of their lifestyles is ludicrous. Here's a quick little quiz:

(1) What's the relative physical activity level of Americans today in comparison to what it was thirty, forty and fifty years ago?

(2) What percentage of cardiovascular disease and stroke (America's biggest killers) is due to less than optimal nutritional practices?

(3) Who benefits from arguments that we need to pay more attention to personal lifestyle choices than to structural issues such as fifty million Americans with no health insurance of any kind?

Answers:

(1) Completely unknown. In other words, we might well be more active than we were a generation ago.

(2) Completely unknown. In other words it could well be zero.

(3) Conservatives who want to retain the status quo.

Posted by Paul Campos | May 28, 2007 9:34 AM

Well, I beg to differ. The statistics show that Americans walk less than they used to, and this is certainly the subjective impression you would form in sub-urban America, where parents drive their kids to the end of the driveway to wait for the schoolbus. The kids don't even walk to a bus stop anymore, the bus stops at the end of each driveway.

Relating CV disease and stroke (really the same thing) to nutrition is a little tricky, because after a certain age (which varies for each person) CV disease becomes a normal process of aging. However, there is no doubt at all that losing weight and exercising will lower your blood pressure, and no doubt that having a normal blood pressure is good for the CV system.

So it seems pretty easy to relate CV disease to something as broad as 'less than optimal nutritional practices', and even easier to relate them to a combination of fast-food and driving everywhere in suburban communities where walking is dangerous.

As for who benefits, there's no doubt at all that the poor will benefit from better lifestyle choices. Obesity, alcoholism, and tobacco use are all more prevalent among the poor, and these are habits that give you problems that medical science can't cure. They are also habits that poor people can quit on their own initiative and actually have more money if they do so.

In turn, I will set my own study question. Who would enjoy better health and more money,

a) the poor person who walks or rides a bike everywhere, eats whole grains and never buys from MacDs, and never drinks or smokes, or

b) the poor person who waits for liberals in Washington thinktanks to come up with a health care plan that makes it possible for them to see a doctor whenever they want?

The answer might seem obvious, but, judging from this comment thread, it's not that obvious.

Posted by serial catowner | May 28, 2007 12:30 PM

Paul is actually a little bit funny, because in my suburban neighborhood 50 years ago, mainly white collar, two families had television sets, and none of them had two cars. If you lived within a mile of the school you walked to school.

If you wanted to buy a candy bar with your 25 cent weekly allowance, you rode your bike three miles to the store. Most of the mothers would allow their children to have one bottle of soda pop a week, but this was always accompanied by the reminder that the Jensen children, whose father was a dentist, were not allowed to have any pop or sugar at all.

I can't even remember a fat person in my high school, which had about 1200 students. There was less parking for the students than there was for the teachers.

So, just at a guess, I would say things have changed a bunch since then. You can make your own guess by studying photos from days gone by.

Posted by serial catowner | May 28, 2007 12:44 PM

There are no reliable statistics on overall activity levels from a generation ago. Your guess is nothing more than that. While it's certainly plausible that peoples' jobs have become less physically strenuous, the fitness/health club industry barely existed 40 years ago.

Calling "obesity" a behavior is ridiculous. Smoking and drinking are behaviors (of course moderate drinking is actually good for people, but this fact is too horrifying for our public health puritans to acknowledge). Weight, on the other hand, is related to behavior in complex ways that we only dimly understand. And before you get to that, I realize it's just "common sense" that if all those poor people would stop eating at McDonald's and walk more they would lose weight, but "common sense" is a synonym for "I have no data."

Also, the notion that there were no fat kids in your 1200-person school is extremely implausible. The percentage of the adult American population that was "overweight" in 1960 by today's definitions was 47%, so your memories appear to be highly selective.

Posted by Paul Campos | May 28, 2007 1:20 PM

Paul, my high school did not include the adult American population. None of us were over 19, none of us lived east of the Rockies, and none of us had a sedentary job where you could sit until your bladder screamed 'Uncle'.

Well, I guess we would have to look at a high school yearbook to find out- what's that, you say? We can actually do that? Well, in that case, we should be able to make at least a good guess about the past.

Who knows, maybe we would actually find records of Selective Service medical exams, or even the numbers of fast food burgers sold per capita. None of these, of course, tell us how active people were or are. But sometimes when the numbers become extremely large, you can make a guess.

How do we get to the place where a commenter will say we don't really know whether you will lose weight if you exercise more?

Paul, if you have figured out a way you can exercise more, eat less, and not lose weight, please tell the Army about it. That would be a military revolution that would eclipse gunpowder.

Posted by serial catowner | May 28, 2007 2:56 PM

We don't really know whether people on average lose weight if they become more active. However, almost all intervention studies indicate that attempts to produce weight loss by increasing activity levels don't work.

The notion that there were no fat kids forty years ago is too idiotic to require further comment.

SC, have you ever asked yourself the following question? If exercising more and eating less is a practical strategy for losing weight, and being thin is considered highly desirable in this society, while being fat is punished in all sorts of ways, why are there so many fat people? Have they simply not encountered this amazingly valuable piece of information that you are trying to convey to them?

Posted by Paul Campos | May 28, 2007 3:17 PM

Uh....no.

If your caloric balance (the amount taken in compared to the number of calories used) is negative, you will lose weight.

When you see a comment like Paul's, it's tempting to think that maybe fat people just don't know this very basic fact. Nobody ever went broke underestimating the intelligence of the American public.

But, of course, it's not that simple. 40% of men say they prefer fat women. Reading the personals ads will convince you that a lot of people you think are fat consider themselves to be "about right".

Beyond that are what we call structural problems of society. These include, but are hardly limited to, a shift in jobs from manual labor to office or machine-assisted labor, high levels of passive activities like television viewing or playing computer games, and point-to-point transport by automobile replacing a brisk walk to your destination, or the use of public transit with a brisk walk at each end.

Undoubtedly a lot of people would like to lose weight by exercising, but live in communities where walking or riding bicycles is dangerous, either because of street crime or traffic.

Now, if Paul wanted to say "We really don't know to what extent an automobile-based society with multiple fast food joints at every travel node influences obesity", that would be a perfectly reasonable statement.

But to suggest that burning more calories by exercising than you consume by eating won't lead to weight loss, well, that's just ....

Posted by serial catowner | May 28, 2007 5:10 PM

All this bantering back and worth about how many Big Macs people eat and how far they live from the store is beside the point. The simple fact is that most (indeed, overwhelmingly most) health care problems are not lifestyle related. They are simply the results of A) aging and B) random mischance. No matter how healthy you try to live in the long run (and maybe even in the short run) you WILL get sick and you WILL die. (You may also suffer serious injury along the way, and a lot of "healthy" activities increase your chances of that). For thsi reason we need to get back to the debate about universal healthcare and ghow to get it (not an impossibnle chore since every other cibvilized nation on Earth has achieved this) and leave the puritanical lifestyle sermons for church.

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