A professor used this analogy recently to provoke students to look
more deeply into the complex and intractable factors that determine health status. Biology
and genetics surely are important, he said, but one cannot ignore the environmental,
social and economic factors that influence an individual’s
susceptibility to disease.
Comparing the U.S. health care system to the Titanic is an analogy as hackneyed as saying the system is in crisis. Yet, it remains useful.
An estimated 1,500 people aboard the Titanic’s maiden voyage died
when the ship struck an iceberg. The greatest, most advanced cruise ship
of the time lacked sufficient lifeboat space, and as a result, the total death rate was very high
— about two-thirds of all passengers died.
But an analysis of death rates by steerage class shows that
first-class passengers were twice as likely to survive as third-class
passengers. And among women, who were much more likely to survive than
men regardless of class, only 3 percent of first-class women died compared with 51 percent of third-class women.
Class, wealth and gender affected passengers’ ability to secure one
of the limited lifeboat spots, and ultimately, determined whether they
lived or died. Just like on the Titanic, income and class, which correlate to education level, remain the greatest
determinants of health in the U.S. and most other nations.
While decades (perhaps centuries) of research shows that health status is determined primarily by "upstream" factors, much of the current health policy discussions focus on matters "downstream," such as insurance status, patient safety, the quality and cost-effectiveness of care, and reducing costs. (Admittedly, insurance status and income are strongly related, but research controlling for access to care, shows the poor still have worse health outcomes.)
The health policy discussion has a slightly different tone in Britain, where the highly regarded Acheson report heavily influences the debate. The 1998 report proposed 39 interventions to improve population health, especially among the disadvantaged, and only three were based on traditional medical care. The authors believed that addressing poverty, employment, education, housing and environmental issues would most significantly improve the public’s health.
Is the current U.S. health policy focus lop-sided, giving too much attention to health system issues, when, in effect, improving education and reducing income inequality would lead to much greater improvements on the population’s health?That’s a tricky question because teasing out causes and the order of determinants is difficult. The current health policy discussions should do a better job of acknowledging that good health is not independent of having a good job, feeling financially secure, getting a good education and the overall feeling that you’re making progress toward a better future for your family. But policies to improve the quality and value in the health system and contain rising health costs are inextricably linked to achieving the former.
Rapidly expanding Medicaid budgets, for example, have forced most states to cut back on education, particularly subsidies to higher education. This has led to significant tuition increases for the three-quarters of students who attend public colleges and universities, and possibly, a decline in quality of those institutions.
The Medicare Part D expansion is another example of the trade-offs between health access and income. As economist Victor Fuchs noted, covering more drugs for seniors is paid for in part by reductions in Social Security. Consequently, the elderly may be entitled to expensive medical care but unable to afford other basic necessities.
The U.S. health care system is often cited as the most technologically advanced in the world when it comes to medical treatment, but just like the Titanic passengers’ fates were determined before they stepped on the boat, our life expectancies depend mostly on what happens before we ever enter a hospital.
Health policy interventions that improve quality and reduce wasteful spending to secure greater value in the system, however, could reduce pressure on other budgetary areas, which are being crowded out by increases in direct health spending but may have equal or greater impact on health status, such as education, safety-net food programs, housing, etc.
Reducing per capita health spending is necessary to focus on more upstream interventions. Achieving spending reductions is a goal without a clear path, but maybe the Titanic offers one more lesson: Surely, it would have been prudent to forgo a few expensive chandeliers in order to have sufficient lifeboats, giving everyone on board an equal opportunity for survival.