In the January 29th New England Journal of Medicine Foller, et. al. published an interesting article, “Population Health–A Bipartisan Agenda for the Incoming Administration from State Leaders.” The first paragraph said a lot.
The common goal of health policy leaders at the level of state government in the United States is promoting the health and well-being of all populations to the greatest extent possible within fixed resource constraints. Our health is affected by our physical and social environments, our genes, our economic and educational opportunities, and to a much lesser degree, the medical care we receive.
The reference that corroborated their assertion, turned out to be an article that I have frequently quoted, the publication in September 2007 of the 117th Shattuck Lecture delivered by Dr. Steven Schroeder at the Massachusetts Medical Society in May 2007.
Schroeder starts by asking an important question:
The United States spends more on health care than any other nation in the world, yet it ranks poorly on nearly every measure of health status. How can this be? What explains this apparent paradox?
The answer to his question is simple:
- The pathways to better health do not generally depend on better health care
- Even in those instances in which health care is important, too many Americans do not receive it, receive it too late, or receive poor-quality care.
Schroeder proposed looking at the determinants of premature death as a key measure of health status and as a way of advancing the discussion of how to improve health. His next insight was:..
…acknowledging the reality that better health (lower mortality and a higher level of functioning) cannot be achieved without paying greater attention to poor Americans.
He was flabbergasted by how complacent most Americans were about the inferiority of our healthcare:
Among the 192 nations for which 2004 data are available, the United States ranks 46th in average life expectancy from birth and 42nd in infant mortality. It is remarkable how complacent the public and the medical profession are in their acceptance of these unfavorable comparisons, especially in light of how carefully we track health-systems measures, such as the size of the budget for the National Institutes of Health, trends in national spending on health, and the number of Americans who lack health insurance.
He then speculated about our complacency:
One reason for the complacency may be the rationalization that the United States is more ethnically heterogeneous than the nations at the top of the rankings, such as Japan, Switzerland, and Iceland. It is true that within the United States there are large disparities in health status — by geographic area, race and ethnic group, and class. But even when comparisons are limited to white Americans, our performance is dismal…
Schroder’s speech presents a pie chart with data that frequently surprises people in and out of healthcare who imagine that their own care is terrific and that we would have a healthier nation if only more people had what they enjoy. Schroeder’s figure suggests otherwise. The pie chart shows the relative percentages for the causes of premature death.
- Behavioral patterns i.e., smoking, alcohol, drugs, overeating, and lack of exercise: 40%
- Genetic factors over which we have no control: 30%
- Social circumstance like unemployment, poor housing, and poverty: 15%
- Environmental exposures: 5% of time.
- The big surprise is that a lack of medical care is the problem that leads to only 10% of early deaths.
Schroeder explains his point by saying:
Health is influenced by factors in five domains — genetics, social circumstances, environmental exposures, behavioral patterns, and health care.When it comes to reducing early deaths, medical care has a relatively minor role. Even if the entire U.S. population had access to excellent medical care — which it does not — only a small fraction of these deaths could be prevented. The single greatest opportunity to improve health and reduce premature deaths lies in personal behavior.
Most of us want to make things better and believe that facts and experience enable those objectives. Schroeder’s argument based on the facts is a challenge to medical practice, as it is generally practiced:
Clinicians and policymakers may question whether behavior is susceptible to change or whether attempts to change behavior lie outside the province of traditional medical care. They may expect future successes to follow the pattern whereby immunization and antibiotics improved health in the 20th century. If the public’s health is to improve, however, that improvement is more likely to come from behavioral change than from technological innovation. Experience demonstrates that it is in fact possible to change behavior, as illustrated by increased seat-belt use and decreased consumption of products high in saturated fat. The case of tobacco best demonstrates how rapidly positive behavioral change can occur.
Many physicians consider the social determinants of health to be the responsibility of others, like politicians, teachers, employers, or even the police. What is often not considered is that as healthcare professionals the resources that we use to provide care for that 10% of the reasons that people die “before their time” takes valuable resources away from the effort to improve the other determinants of health. He stresses that class, not race, is the biggest issue for the individual.
Improving population health will also require addressing the non behavioral determinants of health that we can influence: social, healthcare, and environmental factors…With respect to social factors, people with lower socioeconomic status die earlier and have more disability than those with higher socioeconomic status, and this pattern holds true in a stepwise fashion from the lowest to the highest classes. In this context, class is a composite construct of income, total wealth, education, employment, and residential neighborhood. One reason for the class gradient in health is that people in lower classes are more likely to have unhealthy behaviors, in part because of inadequate local food choices and recreational opportunities. Yet even when behavior is held constant, people in lower classes are less healthy and die earlier than others. It is likely that the deleterious influence of class on health reflects both absolute and relative material deprivation at the lower end of the spectrum and psychosocial stress along the entire continuum. Unlike the factors of health care and behavior, class has been an “ignored determinant of the nation’s health.” Disparities in health care are of concern to some policymakers and researchers, but because the United States uses race and ethnic group rather than class as the filter through which social differences are analyzed, studies often highlight disparities in the receipt of health care that are based on race and ethnic group rather than on class.
The reality of lower and falling life expectancy of blue collar and impoverished populations, and perhaps even the election of Donald Trump to the presidency achieved by understanding the issues of class and those who fear falling further from their previous status in the middle class, confirms Schroeder’s insights from a decade ago. I needed to bold his answer to the best question not usually asked, “What part of the problem are we.”
When public policies widen the gap between rich and poor, they may also have a negative effect on population health. One reason the United States does poorly in international health comparisons may be that we value entrepreneurialism over egalitarianism. Our willingness to tolerate large gaps in income, total wealth, educational quality, and housing has unintended health consequences.
Schroeder is not deemphasizing the need for universal access to healthcare. He is just saying that universal access alone is an inadequate strategy to improve the health of the nation.
Although inadequate health care accounts for only 10% of premature deaths, among the five determinants of health, health care receives by far the greatest share of resources and attention…In the area of access, however, we trail nearly all the countries… Lack of health insurance leads to poor health. Not surprisingly, the uninsured are disproportionately represented among the lower socioeconomic classes.
Perhaps the reason I like this article so much that I approach it with reverence is that Schroeder does sum it all up in a logical and defensible strategic recommendation. He suggests that if we want different results we must take a different approach. He was right ten years ago and he is right now. Buried in his statement along with the recommendation is also a criticism of the status quo and our national error.
Since all the actionable determinants of health — personal behavior, social factors, health care, and the environment — disproportionately affect the poor, strategies to improve national health rankings must focus on this population. To the extent that the United States has a health strategy, its focus is on the development of new medical technologies and support for basic biomedical research. We already lead the world in the per capita use of most diagnostic and therapeutic medical technologies, …It is arguable that the status quo is an accurate expression of the national political will — a relentless search for better health among the middle and upper classes. …The result is that only when the middle class feels threatened by external menaces (e.g., secondhand tobacco smoke, bioterrorism, and airplane exposure to multidrug-resistant tuberculosis) will it embrace public health measures. In contrast, our investment in improving population health — whether judged on the basis of support for research, insurance coverage, or government-sponsored public health activities — is anemic…no government department or agency has the responsibility and authority to meet these goals, and the importance of achieving them has yet to penetrate the political process.
Schroeder believed that the status quo was a function of the fact that the disadvantaged were not well represented in our system of government. Will Donald Trump, elected using the votes of many disadvantaged white voters, change the reality that Schroeder saw when he suggested that those trapped in the environments of the lower class did not have a political voice? Schroeder suggests that for the disadvantaged to be able to participate in America’s greatness they must have a representation that will advocate for more resources to improve health-related behaviors, reduce social disparities, increase access to health care, and reduce environmental threats. Is that what the President will do with his “mandate” from disadvantaged white voters?
Schroeder then made three more profound observations that must be considered if we want to achieve
Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness.
- To the extent that poverty is viewed as an issue of racial injustice, it ignores the many whites who are poor, thereby reducing the ranks of potential advocates. [President Trump recognized this. It remains to be seen if his election will improve their lot.]
- The relatively limited role of government in the U.S. health care system is the second explanation. [Given the politics of the moment that role is likely to get smaller.]
- The American emphasis on the value of individual responsibility creates a reluctance to intervene in what are seen as personal behavioral choices.
Ten years ago Schroeder contended that he was “cautiously optimistic.” He placed his hope in personal efforts to improve health and in the efforts of healthcare professionals to “become champions for population health” as “one of the most productive expressions of patriotism.” He issued a warning as well as the reason for trying to change:
Improvement in most of the other factors requires political action, starting with relentless measurement of and focus on actual health status and the actions that could improve it. Inaction means acceptance of America’s poor health status.
Improving population health …could enhance the productivity of the workforce and boost the national economy, reduce healthcare expenditures, and most important, improve people’s lives….it is incumbent on health care professionals, especially physicians, to become champions for population health. This sense of purpose resonates with our deepest professional values…It is also one of the most productive expressions of patriotism.
To that noble expression of professionalism I say,”Amen!”