Health Insurance Doesn’t Necessarily Mean Better Health

Health Insurance Doesn’t Necessarily Mean Better Health

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By JIM MARKS, MD MPH

A new study in the influential policy journal Health Affairs gives added credence to the idea that much of what drives health falls outside of the realm of medical care. In fact, this must-read study points out what so many of us know: that simply providing someone a health insurance card is not enough to make them healthy.

What better place to test this theory than in Canada – our northern neighbor with a publicly financed universal health care system. Researchers looked at nearly 15,000 Canadians in the nation’s health system who were free of heart disease and tracked them for at least a decade.  Not surprisingly, people disadvantaged by little education and low income, used the health care system more than those with higher incomes. But more importantly, this increased use of services had no discernable effect on improving their health or cutting their death rates – the ultimate bottom line – when compared with others with higher education, higher income and LESS usage of health care.

Almost all of the debate about health care here has been about how many Americans will be covered, for what care, and at what cost. The results of this Canadian study are clear. It may be helpful to have insurance to get care, but the United States cannot expect that giving people medical care will diminish differences in health outcomes or the likelihood of an early death among disadvantaged people. The authors explicitly warn against relying on universal coverage to eliminate inequalities in health.

Although genes and medical care are vitally important, we’re increasingly understanding that where we live, learn, work and play affect our health even more. That is clearly what we saw last year when we released the first look at what factors affect health in every county of the nation.

When we release the new 2011 County Health Rankings in late March, we will see once again that the county you live in, and things like the extent of a person’s education, the quality of the air where they live, and access to healthy foods, can affect how healthy someone is and how long they will live. The good news is that these community and social characteristics that influence health so dramatically  can themselves be greatly influenced by policies and actions in communities working together to build safer neighborhoods, improve access to nutritious foods, ensure that people live in safe housing and provide quality education for their kids. Using these characteristics as a measure, we know more about how healthy a community is as a place to live.

Let’s take an example of a new type of program called Health Leads, where doctors act to remove the social barriers that get in the way of people taking the actions they need to be healthy. In addition to dispensing traditional medical therapies, doctors in these clinics also literally issue prescriptions for food or heating assistance to struggling families, or stable housing for a single mom that does not exacerbate her son’s asthma. A team of college volunteers then helps connect vulnerable families to those community resources that can immediately benefit their health.

The Health Affairs study adds to the mounting evidence that investing in public health, and those non-medical factors that are key to preventing disease and promoting healthy behaviors, is as essential to creating a healthy nation as expanding access to medical care. We have to be honest with ourselves that good health begins, and is nurtured and sustained, in our homes, neighborhoods, workplaces and schools. And if we are serious about bending the cost curve, we have to stop focusing just on treating disease after damage to our health has occurred and focus more of our efforts on preventing it.

To read the article “Lesson from Canada’s Universal Care: Socially Disadvantaged Patients Use More Health Services, Still have Poorer Health,” visit healthaffairs.org.

James S. Marks, M.D., M.P.H., is a senior vice president at the Robert Wood Johnson Foundation. He directs the Foundation’s public health work, including the County Health Rankings, which was launched in 2010 in partnership with the University of Wisconsin Population Health Institute.

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50 Comments on "Health Insurance Doesn’t Necessarily Mean Better Health"


Guest
Feb 26, 2011

Terrific post. Health does not equal health insurance nor medical care. Once we get into the business of improving health (with real metrics around it), then disruptive approaches have the potential to take hold.

Guest
Feb 26, 2011

Very interesting.

“Although genes and medical care are vitally important, we’re increasingly understanding that where we live, learn, work and play affect our health even more.”

Google “HIA”

Guest
Feb 26, 2011

“Socially disadvantaged patients have poorer health”

“Modern curative medicine can’t help them (much)”

Yet another study confirms these well known facts.

Guest

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Admin
Feb 27, 2011

Technically correct but wrongly directed article, Jim. Real Health Economics 101 stuff. Yes social determinants of health well outweigh the impact of medical care on population outcomes. And yes we require social policies to change those social determinants. BUT the reason to give people insurance is not to improve their health per se; instead it is to insulate them from the huge personal COSTS of medical care which they require due to the effects of the determinants of ill health (or to protect them even if they don’t require it and are unknowingly receiving unnecessary medical care).

Egalitarian and affordable insurance is not about people’s health–it’s about their wealth.

Guest
sr
Feb 27, 2011

Agree 100%. Thanks for the comment.

Guest
Lissette Blondet
Mar 3, 2011

Excellent point. Thank you.

Guest
Killroy71
Apr 22, 2011

thank you for the dose of reality, Matt — insurance of any kind is a shield against catastrophic loss.

But many of us came of age in the $10-HMO copay era of “prepaid health care. ” And as much as people came to hate HMOs (which did actually hold down costs), theyare REALLY ticked that the cost of medical care has forced insurers to make leaner coverage products (to keep premiums from going completely crazy) that harken back toward that earlier concept of indemnity, and away from the rich coverage of the recent past.

Everybody likes “choice” and “free” health care — but they don’t want to pay for it.

Guest
Peter
Feb 27, 2011

“The authors explicitly warn against relying on universal coverage to eliminate inequalities in health.”

Universal coverage is meant to eliminate inequities of access to healthcare, changing cultural bad habits affects system costs and outcomes. Public education is meant to provide access, it doesn’t change where we live or who we get our core values from, and it can’t fix stupid.

Guest

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Guest
Fannie
Feb 27, 2011

I disagree with Matthew Holt who appears to be building on a cracked foundation. Medical care does not have to be so expensive. Hospitals are raping the public and insurance carriers, furthered by EMRs that promote fraudulent billing put in the hands of the hospital doctors. Building further, and supported by Dr. Holt and other HIT succups on this blog, HIMSS and CCHIT have deceived Congress into wasting tax dollars on systems of no proven safety and efficacy. There are countless business sprining up to feed at the money trough created by people who know nothing about the right care, with the right treatment, at the right time. Neiother insurance nor EMRs are the answer. Try educated and properly trained human resources. There you go.

Guest
Feb 27, 2011

Fannie. I may be a “succup” but please don’t accuse me of being a doctor. Oh and I agree with you on the “health care costs too much” argument and have been on record for a LONG time as saying that only in a universal care system where there’s no room to force people out via the price effect can we get costs under control.

However, we have lots of human resources in health care, and the more we put in the more it costs

Guest
Peter
Feb 27, 2011

Hey Matthew, this is off topic but I found no other way to contact THCB about site problems. Word press doesn’t have an email. I can’t get my comment posted on,

“Five Things Hospitals and Health Systems Have to Get Good at Fast”

Each time I try to post I get a statement saying, “Duplicate comment”, but the original is not there.

Guest
Frank de Libero
Feb 27, 2011

Good post and nice catch. For whatever reason I missed that HA article. I was looking for an intuitive way to convey to the average engaged citizen that SDOH are very important for population health outcomes — it’s not just healthcare — and you pointed me to it. BTW, this is for a short essay exposing the fallacy of “The US spends more on healthcare but has worse outcomes.” Thank you.

Guest
Hospital_RN
Feb 27, 2011

I wanted to reply to Fannie and anyone else who thinks “hospitals are raping the public.” Hospital care is expensive, yes, however you and the author of the article seem to be missing the point that insuring everyone would help avoid unnecessary ER use and avoidable hospital admissions for the uninsured. This fact alone would likely make Universal Health Care, or whatever you want to call it, pay for itself. Currently, hospitals accept and treat all of the uninsured patients who delay seeking treatment until they are gravely ill, because they cannot afford to go to the doctor. Hospitals do whatever it takes to save these patients, and very often do not receive a dime in payment for their care. Uninsured patients are often kept in the hospital longer than insured patients. This is because no rehab facility, nursing home, or home care agency will accept a patient who cannot pay. So hospitals care for these patients until they are well enough to care for themselves, or until they qualify for Medicaid (which rarely happens). If these patients were insured, perhaps they would seek outpatient care for their ailments and be treated before their illness became life threatening. So you are correct, medical care does not need to be so expensive. However, having so many uninsured folks is one of the factors driving up costs for everyone.

Guest
Feb 27, 2011

This is a stretch. Rather than saying we should double down on payment for the most expensive late-stage care through locking in insurance for all…wouldn’t it be more cost-effective (and impactful) to remove the EMTALA requirements and focus on bulking up payments for primary care and retail clinic use via Medicaid?

At the end of the day, we should aim for a world where hospitals are not needed? Today we allocate 80% of resources into minimally effective sick care and less than 5% into preventing illness in the not-already ill.

Guest
Hospital_RN
Mar 13, 2011

Well I agree with you that preventing illness would be a much better use of our resources. I would LOVE to be in a world where hospitals are not needed, and where I am not needed as a hospital RN. Right now I practically need to clone myself as much as I am needed.

Guest
Adi Sasongko
Feb 27, 2011

From my experience in Indonesia, most of the resources own by private insurance company and government insurance organization, are spent for treatment or medical intervention. There has been practicaly no allocation for health prevention or health promotion. Without good prevention and promotion activities, how can we expect people will be in better health with health insurance?

Guest
Brian Smith
Feb 27, 2011

It seems rather silly to think that access to health insurance would immediately change a person’s health outlook. Yes, the rich, the educated, and the previously insured are more likely than those who haven’t to have access to better diets and exercise and have been encouraged to use it. That doesn’t mean that providing access to health services and encouraging better behaviors won’t create changes in health and diet over time. That’s like saying that students who are disengaged in failing schools should not have access to better ones because they will continue to fail to study. Habits change over longer periods of time than that. Success may not be able to be determined in months or even years. Success may not be visible for years, perhaps even over decades.

Guest
Feb 28, 2011

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