Even as lawmakers in Washington, D.C., drove themselves into a bitter partisan divide over federal health reform in 2010, an unusual experiment across the country in Oregon was amassing evidence that the rancorous debate in Congress was focused on many of the wrong things.
And if what Oregon’s experience is telling us now is accurate, the Affordable Care Act will be neither the boon to America’s health that its supporters claim nor the threat that its detractors fear it will be.
Why? Because expanding access to health insurance and even health care – the primary goal of the ACA – might not make us healthier, at least not in the short term and not in the ways most people seem to believe.
Factors other than health care – income, education, the environment and our own behavior – are much more likely to be connected to health outcomes and life expectancy. The things you do and the things that happen to you before you ever enter a doctor’s office – and after you leave – ultimately determine how long and how well you live.
Sure, doctors and hospitals can save lives, and few of us would volunteer to go without them. But think of your body like your car and (with apologies to the medical profession) your doctor as your favorite mechanic. If you park your car outside in the sun or the snow, if you drive it thousands of miles a month, if you use cheap gas, run low on oil and forget to fill the transmission fluid, that car is going to break down. A mechanic might be able to get it running again. But if nothing changes, the car will be back in the shop in no time, or quit working altogether years before it should.
Our bodies are similar. Health care can patch us up, but it can’t really keep us healthy. It takes a lot more than that to do the job.
Consider what happened in Oregon. That state decided to expand its Medicaid program for the poor in 2008 but didn’t have enough space for everyone who wanted to enroll. So the state drew 30,000 names by lot from a waiting list of 90,000. The lucky ones were given a Medicaid card and free health care. The others remained uninsured.
This unusual decision turned out to be a boon to health care researchers. They followed both groups – the health care haves and have nots – to see how having more or less access to care affected their health.
The results: Those who got insurance saw doctors more often, got more preventive care and even used emergency rooms more than those who remained uninsured. But after two years, the study found no significant improvement in several key measures of health that can typically be affected by 24 months or less of medical care: hypertension, high cholesterol and diabetes.
Oregon’s data are preliminary, but other studies have shown similar results.
Researchers in Canada, for instance, found a mirror image of Oregon that makes the same point: Even when everyone has access to the same level of care, health outcomes differ widely, probably because they are determined by factors largely beyond the control of health care providers.
Canada has universal health care free at the point of service. But researchers at the University of Montreal found that control of the symptoms of Type 1 diabetes in children was still closely correlated with family income. Even when all the children studied were properly diagnosed and given the same prescriptions, children from high-income families did better than those from poorer families. The likely reason: Kids in wealthier families had more support at home, and that support led them to keep to the strict diet and medication regimen that diabetics must follow to control their disease.
This link between health and wealth is a common thread that runs through much of the research on health and longevity. Nobody knows exactly why poor people tend to have poorer health, regardless of their access to health care. The reasons might seem obvious at first, but they are complex. And they form a web of connections in a feedback loop that makes it difficult to discern where the “cause” ends and the “effect” begins: education, environment, personal behavior – including diet, smoking and alcohol use – and one factor that might trump them all, stress.
None of this comes as a surprise to researchers at the University of Wisconsin, who have created a system ranking every county in the United States by the health of their residents. After reviewing their own data and surveying study after study on the question, the Wisconsin researchers have concluded that health care probably accounts for 10 percent to 20 percent of a person’s health and longevity.
If you want to find out how long someone will live, in other words, don’t ask if they have health insurance. Ask them their ZIP code.
The rankings for California found these five counties to be the healthiest: Marin, Placer, Santa Clara, San Mateo and Yolo. The least healthy? Lake County was the worst, followed by Del Norte, Siskiyou, Kern and Modoc.
One statistic used to rank the counties is premature death, another way of looking at life expectancy. That’s defined as the number of years of life lost before age 75 for every 100,000 people. On one end of that scale, the most recent numbers showed Marin had 3,782 years of life lost prematurely. In nearby Lake County, the figure was nearly three times as high, at 9,804.
Most Californians could tell by glancing at those lists that the healthier counties are the wealthier ones. But there are many other differences. Residents of the healthier counties are more likely to have attended college and less likely to be unemployed. People in the less healthy counties are more likely to smoke, be obese and give birth as teens. And generally, a person living in a less healthy county is more likely to be a victim of violent crime.
People who are low-income, poorly educated, more likely to be unemployed and at higher risk for violent crime are also living lives filled with stress, and those unrelenting pressures can take their toll on health, directly and perhaps by leading to unhealthy behaviors. A little bit of stress can be good for you. It stimulates the mind and body. But too much of it can be debilitating.
A seminal study in England a generation ago found a correlation between the health of British civil servants and their place in the bureaucracy’s pecking order, despite universal access to health care. The connection was so strong that it appeared even near the very top of the civil service, with those in the second tier having worse health than their peers right above them, and so on down the line. Differences in employment grade, in fact, proved to be a better predictor of heart disease than rates of smoking, high cholesterol and bad blood pressure.
One conclusion: The daily stress of life, feelings of empowerment (or lack of it), social isolation and financial insecurity were capable of acting on our bodies to cause physical health problems. More recent research has increasingly focused on the hormone cortisol, which our bodies release when we are under stress. People under constant pressure just to survive or get by day-to-day might be subjecting their bodies to a cortisol overdose that can lead to all manner of health problems, including obesity.
Which leads us back to those Medicaid recipients who won the Oregon insurance lottery. That study didn’t find any short-term improvement in hypertension, blood cholesterol or diabetes. But it did find one interesting difference between those who got insurance and those who did not.
The group that got insurance had a 10 percent reduction in diagnoses for depression compared with those who were left behind. And it’s probably not a huge leap to conclude that their improved mental health was related to the fact that they also reported big decreases in out-of-pocket spending for health care, lower levels of medical debt and less need to skip payments on medical bills. Being on Medicaid virtually eliminated catastrophic medical expenses, defined as exceeding 30 percent of a person’s income.
In the long run, the reduction in stress they enjoyed thanks to their increased level of financial security might do more to improve their health than all the doctors, drugs and hospitals that insurance made available to them.
And in the end, that might be the most important lesson for supporters and critics of health care reform: If the goal is to live longer, happier lives, we need to focus as much on the health as we do on the care.
Daniel Weintraub has covered public policy in California for 25 years. He is editor of the California Health Report at www.healthycal.org. Reach him at firstname.lastname@example.org.