Separating Fact from Fiction and Health from Health Care


James S. Marks In an editorial on Wednesday, The New York Times debunks the often-cited claim that America has the best health care system in the world.  For the politicians who routinely use this as a plank in their efforts to stifle reform, the Urban Institute study (disclosure: this study was funded by the Robert Wood Johnson Foundation) is an objective rebuke. The U.S. health care system is not the best – far from it.  And Americans, with a life expectancy that still trails many other countries, are not the healthiest people in the world.

Clearly, this country desperately needs health reform.  But the study, the editorial, and the entire current discourse around health care neglect an important truth about reform: fixing the health care system alone will not significantly improve Americans’ health.

For example: medical spending consumes 16 percent of the U.S. GDP and is projected to reach a staggering one dollar for every five earned by 2018.  And yet, only 10-15 percent of preventable mortality is linked to health care.  This and our terribly poor international rankings in length of life are telling signs that our tremendous investment does not do enough to address the factors that make us sick in the first place.

Our current national debate must look beyond health care – the so-called repair shop of our health system – and focus on our health.  Fixing health care will require insurance reform, cost containment and sound economic policy.  Fixing health will require us to look at our neighborhoods, our schools and our workplaces.  From our earliest years of life, these are the places that determine how long and how well we live in America.  The recommendations of the Robert Wood Johnson Foundation Commission to Build a Healthier America, which identify pockets of success where programs are making a real difference in people’s health, provide a useful place to start.

In schools, where obesity threatens the current generation of children with sicker and shorter lives than those of their parents, solutions are critically needed.  By guaranteeing daily physical activity in schools – which fewer than 3.8 percent of elementary schools provide – and linking federal funds for school meals to their nutritional value, we can reverse the epidemic and help our children grow up healthy.

In our neighborhoods and communities, we must consider the health impact of investments and development to ensure that they help promote physical activity, make healthy foods more readily available and lay a foundation for prosperity.  With public-private partnerships, we can bring grocery stores and nutritious food into underserved neighborhoods and help both the stores and the neighborhoods thrive.  By incorporating bike lanes, sidewalks and trails into our transportation planning, we can help make the daily lives of Americans more physically active.

All of this amounts to a change in the way we think about health in this country.  Health care reform, while critically important, will not avert the crisis of poor health that we’re facing.  The Times editorial and Urban Institute study shine an important light on the dubious claim that we have the best health care system in the world, but they don’t go far enough.  It’s time that we debunk the larger myth, that Americans are the healthiest people in the world, so all of us – from the halls of Congress to the family dinner table – can start working to improve the health of the country we love.

Dr. James S. Marks, M.D., M.P.H., senior vice president at the Robert Wood Johnson Foundation and director of the Foundation’s Health Group.  Dr. Marks oversees all of the Foundation’s work in childhood obesity, public health and vulnerable populations.  Prior to RWJF, Dr. Marks was an assistant surgeon general and director of CDC’s National Center for Chronic Disease Prevention and Health Promotion.

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23 replies »

  1. Hi People,
    This is a great article, From last many years we have taken our knowledge to great height and still lots of fiction exists. We need to differentiate it from fiction. Well see what happens. Do keep us update.

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  3. This is a great post. When you say, “… fixing the health care system alone will not significantly improve Americans’ health,” you make an excellent point. There are still plenty of issues that need to be addressed like Americans not taking proper care of themselves despite having health care.
    You’re right when you say how health care and health can be two entirely different things. Though we do need a reform on health care, it isn’t going to help problems like childhood obesity or even obesity into adulthood. More physical activity must be done, and one must eat better foods to stay healthy.

  4. Thanks for the comment Tamika and others who commented on hers. Your points are well made and amplify what I was trying to say. Most people when they think of causes of good or ill health think of biologic mechanisms. But equally fundamental causes of health or illness are how our communities are built, what our policies or laws encourage/permit or inhibit in housing or transportation or schools. But people do get it when it is framed as the the toxins or microbes one is exposed to in their neighborhood, the safety of the community or worksite, whether one smokes or is physically active etc. But until we look beyond medical care for those things that matter a lot for protecting and preserving our health and the health of those we care about we will fail to become the healthiest nation and continue to spend much more than we need to. We need less disease and injury just as much as we have to have good health care for all those who need it.

  5. Thanks for the comment, Meg You are right that I should have included that the report was one that we supported and it has been added it to the post. For those who would like to see the whole report, it is on our website. http://www.healthreform.org This site has lots of other reports and materials on the issues and debates.

  6. Tamika, that’s so important. I read a great article last summer on relative deprivation called “Unequal America” (http://harvardmagazine.com/2008/07/unequal-america.html). “If people are worried about their basic needs of survival and security and food and shelter, they cannot worry about the fact that a cigarette is going to cause lung cancer 20 years from now.”
    I’m still haunted by this statistic: “American respondents were much more likely than European respondents (71 percent versus 40 percent) to agree with the statement that the poor could escape poverty if they worked hard enough.”

  7. Well said Tamika. The problems we call healthcare problems are actually deeper societal problems that have spilled over into healthcare. Greed, selfishness, impatience, and myopic thinking can be found throughout society, and I think at least a little bit of them are in all of us.
    Government has increasingly become an entity which protects us from ourselves. At what point to do we stop with the workarounds (bundled payments, public option, etc.) and address the problems directly. Anyone that thinks we can “fix” the healthcare and financial sectors and life will be sweet is naive. If it takes legislation or regulation to fix something, was it really fixed?

  8. There’s an interesting commentary in the August 12 JAMA on addressing health problems through “structural interventions” (http://jama.ama-assn.org/cgi/content/extract/302/6/683 – subscription required). Telling people to change their diet and to exercise more hasn’t been very successful. If the environment contributes to poor health – lack of fresh fruits and vegetables and safe places to play in poor neighborhoods, pollution, pesticides – why not change the environment to make it healthier? More physical activity in schools, as James mentions, also promoting urban design that allows walking to schools and stores, bicycle paths, wider sidewalks, menu labeling in restaurants, school salad bars. Even things as simple as prominently displayed signs that indicate where the stairs are located.

  9. There are many valid points within this blog. There should be a separation between health and healthcare. In order to have healthier individuals other factors must be considered for this perspective to be successful such as a change in economic distress and the deviant social behaviors of the American people. For example, the introduction of affordable healthier grocery stores, bike lanes and etc. are wonderful suggestions but the reality of them being beneficial in the communities that are in are in jeopardy is questionable. Survival is what people are facing at this time. How can we handle child hood obesity, when we are afraid to let our children go outside the home or participate in girl or boy scouts without being molested? The changes in the school’s curriculum to ensure physical activity within a school day is helpful as well as nutritional lunches but the actuality of policemen acting as security guards to make sure that students can attend their classes is ridiculous. Every day children are caught in a cross fire of gun violence and kidnapping from pedophiles, in addition to single or dual parent homes ability to provide supervision for outdoor activities. “Living life” is killing us. Health care reformations, policies nor debates and town hall meetings can save us, if we don’t alert our attention to the everyday cruelties in this nation that prevents us from elevating. What should be the priority? There is an unspoken silent war occurring and Americans are losing against themselves. It would be wonderful for everyone to receive health care. It was best stated that, there is only one piece of pie and everyone wants a piece but some don’t like the flavor, others don’t want to share and some refuse to pay money for a larger or another pie. In order for health care reform to work there has to be some changes made socially as well as economically. America is able to cause peace and rebuild other nations and yet within our own country people carry guns to presidential town hall meetings, spitting at one another, yelling and screaming like we are in a backyard brawl because we are about to be forced to share the piece of pie and yet we call ourselves a civilized nation. Health should be separated from healthcare when speaking of reform but it should include socialization and economic reform.
    Health care reform alone will not make us healthier Americans. This will not happen overnight and it will not be anyone’s fault but our own.

  10. Shame on you for not disclosing that the Robert Wood Johnson Foundation funded the “objective rebuke” this blog is based on. If it’s so objective, what are you hiding?

  11. Thank you Dr. Marks for making the distinction between population health and health care. I believe Tim reinforces the semantic trap we are currently in regarding reform. Many have said that Population health (which explains the counter intuitive facts that Americans have the most costly “system” and yet mediocre overall health)is derived 50% from culture (personal behavior)+ 40% gestational and genetic endowments + only 10% from the “health care delivery system.” I believe using the term healtcare delivery avoids the semantic fog exhibited by Tim. Yes, we could have the perfect healthcare delivery system for the ill yet have poor population health. Preventative care begins way before one sees the physician as many have noted. We must change the culture to optimize health while being prudent with spending on the delivery system. Rob MD

  12. Mr. Marks – Excellent post! It’s refreshing to hear a non-partisan, pragmatic view for a change. I’m working on a community-wide initiative to address the obesity epidemic in my local area. The goal is to address all of the societal/environmental factors contributing to unhealthy lifestyles, in addition to the individual factors. I’d love to discuss it with you if you’re willing. You can find my e-mail address by linking to my blog.

  13. James, Great statement.
    In anticipation of our conference call, please note the following:
    Letter to the Editor New York Times
    Instilling Healthy Habits
    Published: July 19, 2009
    To the Editor:
    Re “A Strong Health Reform Bill” (editorial, July 16):
    As comprehensive health care reform takes center stage, President Obama and our legislative leaders once again are facing the inevitable challenges of paying for health care. Emphasis on the importance of early childhood health promotion, health education and disease prevention will have an impact on a person’s health over a lifetime, probably more than any short-term medical intervention solutions being proposed.
    Public school health policies and curriculums are the responsibility of local school districts. One of the most important actions Congress can take to encourage more schools to incorporate K-12 health education in the curriculum is to support established national school health standards.
    Early childhood and K-12 comprehensive health curriculums have influenced reduction in smoking, decreased alcohol consumption and reduced childhood obesity.
    This call for action is directed toward all three sectors — government, business and nonprofit — in concert with parents. The new federal stimulus package can provide a new 21st-century curriculum, train teachers and community-based organizations, and activate the business community, especially the food industry and mass media.
    Progressive change will happen only when the will of the nation’s educators, with support from health leaders and parents, moves early childhood and K-12 health education forward as a priority.
    Clarence E. Pearson
    New York, July 16, 2009
    The writer is the former director for health and safety education at MetLife and founding president of the National Center for Health Education.

  14. Tim, I guess it depends on how you define the term “health care”. If it’s defined as “sick care”, then we probably have the ability to provide the best care in the world. That still doesn’t mean that we have the best “system” in the world, because such statement will need to examine other factors, such as equitable delivery and consistency of outcomes.
    If you define “health care” as Dr. Marks defines it to include preventive care, health and nutrition education, etc. (as it should be defined), then our health care system is obviously not good enough, since it seems to be creating more non healthy people than other systems.

  15. “fixing the health care system alone will not significantly improve Americans’ health”
    This is entirely true. We still have to address a lot of things like social and economical factors.

  16. Tim, I think it fair to say our healthcare “system” is not the best in the world. Keeping fat people, diabetics and heart patients alive to be able to live their same destructive lifestyle does not make healthcare the “best”, it does make it the most expensive in a system where providers determine costs.

  17. Just trying to follow this:
    1. Our population is not as healthy as other populations.
    2. This has more to do with lifestyle than anything else.
    3. This proves that our health care is not the best in the world.

  18. Among the other clips of Ted Kennedy repeated throughout the last weekend was an interview from 1980 in which he advocates strongly for investing in wellness to keep people health first. 1980. Glad to see RWJF picking up this flag and getting out in front.

  19. Cubans have excellent longevity, not because of their health care system, but because they don’t have the income to eat too much.

  20. James,
    Thank you so much for bringing this up. This is what we have been saying at http://blogs.biproinc.com/healthcare In a series of articles over the year, we have tried to convince that healthcare can not be fixed unless we look at it from a big system perspective…that would as you said include insurance, poilcy, law, social changes/reengineering, and much more.
    In our belief, it is not possible to reform the healthcare sector to become world class -hence we named our publication Healthcare Transformation.
    No matter how much cost or cut, it will still be high. The best way to look at it would be to look at the whole supply chain in a broader sense…from disease acquisition to treatment. It would cover sociological as well as medical issues.
    I would like to be proven wrong…but I do not see how one is going to solve this problem by complaining about insurance industry when the fact is that they are not the biggest culprit – pls take a look at my article on villians of healthcare reform.
    The solution t healthcare crisis is not difficult and it is possible to create a win-win-win-win-win strategy if we sat together to find a solution for greater good.
    Alternative is everyone is going to pay the price…it is the short term many might believe they are succeeding.

  21. Even though complaints from chronic pain patients are easier to diagnose and document we now have created a situation where doctors are under-prescribing out of fear, especially if their patient are in their last stages of life because the docs can be charged with murder if autopsies shows high traces of pain medication. I pray this madness comes to an end and I sincerely hope none of you will ever be dying in extreme pain in a hospital, nursing home or maybe at your own house while the doctor is afraid to give you that prescription or injection during your last moments. Yes, definitely keep this medication away from kids but do make it available to those who can benefit from it!

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