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.