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 Responses for “Health Insurance Doesn’t Necessarily Mean Better Health”

  1. 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.

  2. BobbyG says:

    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”

  3. Mark Spohr says:

    “Socially disadvantaged patients have poorer health”

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

    Yet another study confirms these well known facts.

  4. [...] in 2010 in partnershipwith the University of Wisconsin Population Health Institute. Tweet this Share on FacebookThe Health [...]

  5. Matthew Holt says:

    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.

    • sr says:

      Agree 100%. Thanks for the comment.

    • Lissette Blondet says:

      Excellent point. Thank you.

    • Killroy71 says:

      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.

  6. Peter says:

    “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.

  7. [...] in 2010 in partnershipwith the University of Wisconsin Population Health Institute. Tweet this Share on FacebookThe Health CareBlog Tags: Better, Doesn’t, Health, Insurance, Mean, [...]

  8. Fannie says:

    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.

  9. Matthew Holt says:

    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

  10. Peter says:

    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.

  11. Frank de Libero says:

    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.

  12. Hospital_RN says:

    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.

    • 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.

      • Hospital_RN says:

        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.

  13. Adi Sasongko says:

    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?

  14. Brian Smith says:

    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.

  15. Barry Carol says:

    Hospital_RN – According to the Kaiser Family Foundation, for hospitals overall, their prices are about 6% higher than they would otherwise be because of uncompensated care. For the safety net hospitals that treat disproportionate numbers of uninsured patients, it’s a big deal but for most hospitals it just isn’t.

    Prices that hospitals actually collect from Medicare and private insurers are far higher in the U.S. than their counterparts overseas for procedures like a CABG or a hip replacement. Yet, presumably, outcomes are similar, the number of people in the OR is similar, and recovery time is similar as well. Prices for outpatient procedures are also much higher in the U.S.

    I have never seen a good analysis that compares the cost of operating a U.S. teaching hospital or a community hospital vs. one in Western Europe or Canada. Labor costs are far an away the largest operating expense for hospitals. How many employees does it take per licensed bed to run a hospital in the U.S. vs. a similar hospital in other developed countries? It is also important to note how hospitals are financed. In Switzerland, for example, a meaningful percentage of hospital operating costs are paid for by general tax revenue. This allows hospitals there to charge insurers and patients less for their work than they would have to otherwise. So, we really need to know whether the much higher hospital reimbursement rates in the U.S. are due to differences in financing, differences in pay and benefits earned by hospital employees or differences in operating efficiency and how much unnecessary testing is done while the patient is in the hospital.

    • Hospital_RN says:

      I am sure you are not suggesting that hospitals decrease pay to the RN’s. We are having enough trouble recruiting qualified persons into the field as it is. Nurses have WAY more responsibility in the US that in other countries, so I don’t think it would be a fair comparison. I can’t speak for what physicians and other employees make, though.

  16. botetourt says:

    Barry–The cost of our hospitals, and our healthcare system, is largely a factor of the number of hospitals and physicians (and every other kind of healthcare outlet) plastered over this country. You can take any hospital, increase its scale, eliminate the administrative and clinical overhead required by our state and federal systems, and I believe it would compare favorably with hospitals anywhere (adjusted for local wages and ironically, the cost of health care for employees). How much would Fords cost if we had plants in every state, each one producing a fraction of what current plants produce? You can’t compare a foreign hospital operation easily to what we have. The problem is, how can we ratchet down the number of providers so we can be reasonably efficient? You can’t ignore RNs comments above, but you are correct in that uncompensated care, like malpractice, defensive medicine, and other bogeys are not the underlying problem.

  17. Barry Carol says:

    Botetourt – It’s not correct to compare auto manufacturing to hospitals. There are tremendous economies of scale in auto manufacturing but not in operating hospitals. Hospital economics are closer to hotels, cruise ships, apartment and office buildings, etc. I don’t think the cost per licensed bed of running a 600 bed teaching hospital, for example, is much different from those at the 14 hospital University of Texas Medical Center in Houston. HCA, which owns some 160 hospitals, may have some modest cost advantages in purchasing supplies and access to capital but that’s about it. It has to pay its people roughly the same as competing hospitals in each market. I have no idea if it operates much more efficiently than competing community hospitals or not but I doubt it. The biggest differences between hospitals in the U.S. and elsewhere, I think, relate to what happens to patients while they’re there. If they have a problem that needs to be diagnosed, we probably do more tests to reach a definitive diagnosis and rule out various conditions, partly to drive revenue and partly to minimize litigation risks. End of life care is also more intense (and often futile) here which drives up costs as well. The more standardized procedures like CABG, hip replacement, imaging and the like may be priced high to cross-subsidize other care. Like I said earlier, though, I’ve never seen a good analysis comparing the costs of operating hospitals in the U.S. vs. those in other developed countries. If anyone is aware of one, please share it.

  18. DeterminedMD says:

    Umm, who are those two tall, hairy individuals against one wall in the room holding up signs in their hands, one saying “population control” and the other holding “quality of life with term limts”? How do you people have these incessant arguments how to improve health care and access when we say nothing, and equally do nothing about the sheer number of people who live in this country and are given full court presses with each and every health event that at times is pushing the boundaries of realistic endpoint to access a return to function that allows for fair independence?

    I do not know who should live or die, but, isn’t it at least foolish to act like this concern should not be addressed? Obviously not to the usual commenters who just want to banter about statistics and political rhetoric to support a limited and usually extremist position.

    Ohh, my bad for raising this question!

  19. Mark Spohr says:

    @Deter…
    You raise an important point in the high cost of “end of life” care. However, you seem to think that the solution requires that we consider some kind of “death panel”. This is not necessary or appropriate.
    The high cost of end of life care is the same problem as exhibited in the rest of the US health care system. That is, overuse of unproven and ineffective procedures and treatments which generate large revenues for doctors, hospitals, etc. but do little to improve health.
    The ACA has a provision to examine and recommend (and eventually regulate) medical procedures and treatments based on their proven effectiveness. If this provision is not torpedoed by those who have a large financial interest in continuing the status quo, it will reduce these unnecessary and ineffective procedures and benefit patients.

  20. DeterminedMD says:

    Thank you for the validation, the rhetoric of the extremists either validating or refuting the concerns by providers that government controlled health care will wind up with these sensationally termed “death panels”.

    Maybe cooler, more moderate speakers can find an alternative term for reveiws of health care interventions that could be viewed as realistic as much as excessive or extreme? Perhaps I could offer one: Standards Of Care For Assessing Interventions Realistically, as in SOCFAIR, because some reviews will feel like the patient is being socked, but in the end the system is in place to be as fair as possible. Just my opinion. Everyone can’t live forever, and, isn’t disease part of the evolutionary process at times? Again, not a wide sweeping generalization, but don’t politicians try to get away with just that!?

    Just also remember, government is focused on cost, but yet clinicians are focused on quality of life. The two don’t overlap so conveniently, eh?

  21. Mark Spohr says:

    The UK NHS has a National Institute for Health and Clinical Evidence (NICE) which is charged with determining the quality, cost and effectiveness of drugs and technology. They have been operating for several years and have quite a body of knowledge on effective (and ineffective) treatments.
    Please note that NICE does have quality as part of its mandate and it is not just politicians trying to cut costs.

  22. Nate Ogden says:

    “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.”

    Its been Universal systems that balloned cost, not only in healthcare but education as well. To say the only solution is that which created the problem makes no sense.

  23. Mark Spohr says:

    “Its been Universal systems that balloned cost, not only in healthcare but education as well. To say the only solution is that which created the problem makes no sense.”

    Nate, I know this is your mantra but the real world doesn’t agree. All of the other 30 developed countries in theh world have universal care and all of the deliver better quality care, have better health outcomes, and better access than the US. As far as cost, ALL of them do this for less than half what the US spends (per capita). Universal care is not the problem… perhaps you should consider it as the solution.

  24. Nate Ogden says:

    Mark if you claim apples in Europe taste better then oranges in the US do you believe that is factual or your opinion? Your argument glooses over so many verables it is meaningless.

    How many of those countries have 12 million illegal South American immigrants? Which South American country has better everything you list?

    Better access to appoved care. See the following as just one example of millions

    http://www.telegraph.co.uk/health/healthnews/8349297/Cancer-sufferers-refused-life-extending-drugs-despite-Government-pledge.html

    “Dying cancer patients have been refused costly life-extending drugs on cost grounds despite a Government promise to end the “scandal” forever.”

    Most dying cancer patients in the US have access to these drugs. In this case we have better access then the other 30. You pick some arbitrary measure then claim they have better access. To what and based on what?

    What are you using as a quality measure.

    They deliver an apple for less then half of what we spend to deliver a banana, whats your point? Your cost argument is meaningless as the delivered product and underlying systems have no relation to each other.

    More specifically I was referring to the Universal system here in the US. We have a exact model of Universal care delivered in the US and it is a major failure. How would expaning that failure to the entire population improve anything?

    Do you believe Medicare for all is the solution?

  25. KarmaPolice says:

    Why do the poor and under-educated need more health care?

    Because their diets consist of highly-refined carbohydrates, sugar, and processed food.

    75 percent of Americans fall into this category.

    Think about it.

  26. Oily George says:

    The correct study would be one that shows ‘How many Canadians with chronic disease, including cancer lose their whole life income, housing and savings due to their diagnosis.’…How many canucks are in THAT place?

  27. Nate Ogden says:

    Oily how many do you think. I would put it at tens of thousands a year. The follow up question is would you rather die for lack of treatment but die with a house and savings. Or would you prefer to live and have to file BK but still keep your house and car and retirement?

  28. Joel says:

    This study illustrates our current health care ‘system’s focus on ‘failure demand’, that is, fixing health problems after they occur instead of prevention; treatment after the fact vs meeting peoples demand for wellness. It treats health problems the way we fix cars after an accident: fix them up as best we can and put them back on the road. But unlike health care, with autos we invest money in preventing accidents.

    One suggestion for reorienting the health care system from treating failures to supporting wellness is to change the way we pay for wellness: require insurance companies to be responsible for all expenses while receiving a capitation for each patient.

    And if we want real competition, we can empower every citizen with the yearly opportunity to choose a standard benefit plan from three or more insurance companies. Insurance companies would compete by making people healthy or go out of business.

    For single payer fans, the government could pay the capitation fee to each insurance company for each one of their registered patients. The government then would also be very interested in supporting wellness, as would citizens.

  29. Joel says:

    errata: I meant to write that citizens should be able to choose one from at least three health plans. My apologies.

  30. [...] Universal access to health care does not ensure universal good health. This is the unremarkable conclusion of four Toronto researchers. Their published paper has nonetheless attracted the attention of bloggers opposed to universal health care, who cite the study with titles such as “Socialized Medicine Doesn’t Improve Health of the Poor” and “Health Insurance Doesn’t Necessarily Mean Better Health“. [...]

  31. [...] is from Jim Marks, writing at The Health Care Blog. See our previous post [...]

  32. Peter says:

    “I have never seen a good analysis that compares the cost of operating a U.S. teaching hospital or a community hospital vs. one in Western Europe or Canada.”

    Barry, I couldn’t find a comparison but a link the the Canadian Institute of Health Information (CIHI) under a search of Hospital Price Index gives a lot of information on hospital cost breakdown. Here’s the general link as most are in PDF format.

    http://www.cihi.ca/CIHI-ext-portal/internet/en/Search/search/search_main_en?q=hospital%20price%20index&client=all_results&start=0&num=10&filter=0

  33. Barry Carol says:

    “I am sure you are not suggesting that hospitals decrease pay to the RN’s.”

    Hospital_RN – I am absolutely NOT suggesting any decrease in pay for RN’s.

    Since a significant portion of inpatient hospital care is attributable to cases other than surgeries, I suspect that we may do a lot more testing here using more expensive and redundant equipment to reach a definitive diagnosis when we don’t know exactly what is wrong with the patient upon admission. We may also have more private rooms and other expensive amenities. Defensive medicine is probably a factor as well. We know that doctors generally earn considerably more in the U.S. than their counterparts abroad. Hospitals in other countries may have higher average occupancy rates which help to spread fixed costs over a broader patient base. Or, the price differences may have more to do with how hospitals are financed. As I noted earlier, Swiss hospital operating costs are partially covered by general tax revenue leaving less to be covered by bills to insurers and patients. Finally, Medicaid rates are well below actual costs, on average, which has to be made up by cost shifting to private payers, and many hospitals also claim that even Medicare rates do not fully cover their costs either. The bottom line is that it’s a complicated issue. I don’t know either the root cause of the large hospital price differences between the U.S. and other developed countries or how to narrow them materially without putting many of our hospitals out of business.

  34. It’s not just about providing more Americans with better health care. It’s also about getting Americans to care more about their health before it becomes an issue that requires health insurance. The better we take care of ourselves the less frequently we are going to need to see a doctor for much more than a check-up.

  35. Peter Q Wolfe says:

    It’s funny how the insured typically say that “Poor or unfortunant people don’t deserve health care” cause f factors beyond their control not personal responsibility. Is it your ult that you don’t know enoug cause of statistics, genetics, accidents, quality of educatio, crime rates, single parent households, etc? Crazy to think of the U.S.A as a christian naation with the upmost christian values when our actions don’t refledct anything. Instead we blame the poor for being lazy or drunks/drug addicts. Sadly that my sister who has no health care cannot get counseling or rehabilitation cause of the for profit health care industry even today cause of the inequalities of the U.S.A.

    Finally, I think health care investments can be in people on their personal life care. Waht we need is a doctor who is also a psychologist not a mechanic cause humans are not machines. We happen to have mental issus resolving the issues of our day. For example, the nurse could be a nutritional assistant as well and we could save by ivesting in nurses not ddoctors. Most things a rn can do what doctor cannot anyways. My motehr was a nurse in Mckinney, Texas for a while, so I have some insights. Another thign we need o regulate food like fast food restaurants in our communities by eliminati of these taking advantage of the poor i the ly way of doing this. Profitxs don’t come before people is what I say. If that means economics must slow, then let them slow and good riddens for it. Another thing is that we need to educate peopl with more requirements and quit talking down to people about things. For example, all welfare recipentss need to be reqired to have a library with manditory education tests on nutrition, english, and government with economics to understand things not havin access to the stupid cable television on public dime is hat I say.

  36. nate ogden says:

    Nice try Peter Wolfe,

    ” Instead we blame the poor for being lazy or drunks/drug addicts. ”

    We don’t blame the poor we blame the lazy and drunk/drug addicts for being lazt drunk/drug addicts. Its people like you that try to twist the argument for your political benefit. Why are you so intent on giving the lazy and drunk/drug addicts a free pass?

    Since your not able to manage your life you want someone to do it all for you? Not very American or Christian.

  37. Milena says:

    I agree that “simply providing someone a health insurance card is not enough to make them healthy.” I believe that all people should be approached when treated not from the point of view of health insurance, but should be treated the same way.

  38. Tom says:

    Well.. that’s partly true.. yet, in most developing countries, the title statement should be reconsidered..

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