Shorter Lives and Poorer Health on the Campaign Trail — An Idea

This article was published in the March 2016 issue of the American Journal of Public Health.  A related commentary from Stuart Butler of the Brookings Institute (formerly of the Heritage Foundation) follows: 

For those desiring serious and compelling conversation on the presidential campaign trail about the future of our nation’s health, this is a dispiriting time for two reasons. First, candidates have precious little to say about our most compelling challenges relating to the nation’s health as opposed to our medical care. They follow familiar and politically reliable prescriptions on both sides of the partisan divide. Second, the raw material for a rich and potent debate concerning the public’s health has never been more abundant. I have hope that this conversation can occur, though not in the context of the 2016 political circus.

Here is one example of what I would love to hear presidential candidates discuss in at least one debate: the 2013 report from the National Academy of Medicine (NAM) called “Shorter Lives, Poorer Health.”1 It is a 394-page indictment of our nation’s health and health care systems. Here is the opening:

The United States spends more money on health care than any other country. Yet Americans die sooner and experience more illness than residents in many other countries. While the length of life has improved in the United States, other countries have gained life years even faster, and our relative standing in the world has fallen over the past half century.1(p.ix)

Extensive research confirms “a large and rising international ‘mortality gap’ among adults age 50 and older,”1(p.1) according to the NAM panel.

The U.S. health disadvantage cannot be attributed solely to the adverse health status of racial or ethnic minorities or poor people, because recent studies suggest that even highly advantaged Americans may be in worse health than their counterparts in other countries.1(p.1)

The report’s comparison group includes Australia, Austria, Canada, Denmark, Finland, France, Germany, Italy, Japan, Norway, Portugal, Spain, Switzerland, the Netherlands, and the United Kingdom using data between the 1990s and 2008. The health disadvantage was sharpest in nine health domains:

  • Adverse birth outcomes—the highest infant mortality rate among high income countries;

  • Injuries and homicides—a leading cause of death in children, adolescents, and young adults;

  • Adolescent pregnancy and sexually transmitted infections—the highest rate of pregnancies among high income countries;

  • HIV and AIDS—the highest incidence of AIDS and the second highest prevalence of HIV infection;

  • Drug-related mortality—more lives lost to alcohol and drugs than in any other nation, even when excluding drunk driving deaths;

  • Obesity and diabetes—the highest rates of obesity and diabetes among high income nations;

  • Heart disease—the second highest rate among 17 peer nations;

  • Chronic lung disease—higher mortality than in the United Kingdom and other European countries; and

  • Disability—one of the highest prevalence rates of activity limitations among older adults.

The NAM results are not totally bad and include higher survival after age 75 years, as well as better rates regarding cancer, blood pressure and cholesterol levels, smoking, and stroke mortality. Of note, given recent public preoccupations in the political campaign, the health status of recent immigrants is better than that of native-born Americans.

Yet,

Americans under age 75 fare poorly among peer countries on most measures of health. This health disadvantage is particularly striking given the wealth and assets of the United States and the country’s enormous level of per capita spending on health care, which far exceeds that of any other country.1(p.4)

The Report is a staggering indictment of our American society in this new century. Back in 1980s, President Ronald Reagan taught the nation the power of positive thinking in shaping attitudes. This report is downer, which may help to explain why it is so hard to break into the national conversation.

Yet it is also true is that in recent years, we have seen other reports that paint a bleak picture of our nation’s health.

In November, a new study by Case and Deaton documented rising morbidity and mortality rates among US Whites aged 45 to 54 years.2 A reexamination of the data by Aron et al. at the Urban Institute revealed a shocking increase in the rate of mortality among middle-aged women three times faster than the rate of increase among similarly aged White males: 26.8 deaths per 100 000 population among White women aged 45 to 54 years versus a 7.7% increase among men between 1999 and 2013.3 Figure 1 supports Aron et al.’s conclusion:

There is simply no mistaking the reality that American women are currently dying much earlier than their counterparts in other advanced nations … [including] women of reproductive and childrearing ages, a finding that has huge implications for children, families and communities.3

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And not to let US health care off the hook, the performance of our medical care system continues to underwhelm. A recently released study by the World Health Organization and The Economist Intelligence Unit, “Healthcare Outcomes Index 2014,” examining the health care systems of 166 nations, ranked the United States number one in spending and number 33 in quality outcomes, placing it among the least efficient systems on the planet, and ranking behind nations such as Lebanon and Costa Rica.4 Figure 2 shows the broad ranges of nations that achieve better results for their societal investments in health care.

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I recall in the 1980s reading health economists speculate about “flat of the curve medicine,” the hypothetical point at which further expenditures on medical care could actually produce worse health. Figure 2 illustrates that US spending now is beyond the flat of the curve and that the hypothesized adverse outcomes from outsized medical care spending are now real.

Research over the past five years by Bradley at Yale offers a compelling hypothesis to explain at least part of our nation’s dismal performance—among all advanced nations, the United States spends by far the most on a per person basis on medical care while spending nearly the least on a per person basis on nonmedical social service spending such as education, day care, job training, housing support, nutritional assistance, and more.5 Focusing less on medical care and more on needs relating to the social determinants of health seems to help produce more beneficial population health outcomes than our nation’s prioritization on the reverse. Figure 3 illustrates Bradley’s key findings.

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So here we are with an accumulating knowledge base of a deep and profound societal problem. Our approach—or perhaps non-approach—to health is killing us and weakening our nation. Is there a presidential candidate talking about any of this? Yes, Senator Bernie Sanders proposes a Medicare-for-all single payer system that might provide the best opportunity for systemic reorientation. Yet the real-world chances for such a radical redesign do not offer great confidence.

One of the most surprising developments in American politics in recent years has been the emerging common ground from the nation’s political right and left regarding US criminal justice and prison policies that leave us with the world’s highest incarceration rates. From widely diverging ideological perspectives, deeply divided political adversaries are engaging in serious and substantive collaboration to change these policies.

I see the basis for a new conversation between the political left and right regarding our nation’s over-reliance on medical care to address human needs that could far more effectively and efficiently be addressed in preventive and nonmedical ways by tackling the social determinants of health. Surely, citizens who identify as conservatives have no reason to cheer our outsized and debilitating level of spending on medical care. Might we see in the new incarceration dialogues inspiration for a new and path-breaking conversation on how to get our nation’s health care needs and spending in better order?

Although it is already late to get these issues planted in the 2016 national political agenda and campaign, it is not too late to spur conversation and education. While the process for major political change takes time, the work has to begin somewhere. The nation’s public health community has a lot to say and much to contribute to this process.

Let’s begin.

References:

1. SH Woolf, L Aron, eds. US Health in International Perspective: Shorter Lives, Poorer Health. Washington, DC: National Academies Press; 2013. Available at: http://www.nap.edu/catalog/13497/us-health-in-international-perspective-shorter-lives-poorer-health. Accessed January 15, 2016.
2. A Case, A Deaton. Rising Morbidity and Mortality in Midlife among White non-Hispanic Americans in the 21st Century. Proc Natl Acad Sci U S A. 2015;112(49):1507815083. [CrossRef] [Medline]
3. L Aron, L Dubay, E Waxman, S Martin. To understand climbing death rates among Whites, look to women of childbearing age. Health Affairs Blog. November 10, 2015. Available at: http://healthaffairs.org/blog/2015/11/10/to-understand-climbing-death-rates-among-whites-look-to-women-of-childbearing-age. Accessed January 15, 2016.
4. The Economist Intelligence Unit Healthcare. Health outcomes and cost: a 166-country comparison. Available at: http://stateofreform.com/wp-content/uploads/2015/11/Healthcare-outcomes-index-2014.pdf. Accessed January 15, 2016.
5. EH Bradley, BR Elkins, J Herrin, B Elbel. Health and social services expenditures: associations with health outcomes. BMJ Qual Saf. 2011;20(10):826831. [CrossRef] [Medline]
6. EH Bradley, LA Taylor. The American Health Care Paradox. New York, NY: Public Affairs; 2013.

7. L Neff. Actually, the US is NOT spending more than any other country on health. Sojourners. August 1, 2013. Available at: https://sojo.net/articles/actually-us-not-spending-more-any-other-country-health. Accessed January 15, 2016.

Stuart Butler Responds

McDonough is right about two very important things. First, that in America we have quite dismal outcomes for the enormous amount we spend on health care. And second, that there is a real opportunity for a new political dialog between left and right to take root—though perhaps one that is more of a quiet agreement than a high-profile grand bargain.

McDonough wisely draws attention in Figure 3 of his editorial to the sharp distinction between the United States and other Organisation for Economic Cooperation and Development countries in the relative proportions of gross domestic product spent on health services and social services. The United States is a lonely outlier because we overmedicalize our approach to health conditions and community health. Generally a blend of social, housing, public health, and other preventive strategies would yield better health results than calling an ambulance—and at a fraction of the cost. Even our higher survival rates after age 75 years is a mixed blessing, as Gawande points out, because expensive and frequent medical interventions may extend age but often not the quality of life.1

The good news, both substantively and politically in this election year, is the growing recognition that addressing the social determinants of health is a key—perhaps the key—to improving health outcomes while slowing the growth in health spending as a proportion of gross domestic product and public spending. McDonough and I agree on that, despite his affection for Bernie Sanders’ utopian Medicare-for-all, which likely would do little to address the underlying cost and outcomes problem.

So how could a new conversation develop, of the kind both we both would like to see? I think on several fronts.

First, building on existing collaboration, serious analysts and policymakers on both sides of the political spectrum should explain more extensively how resources currently restricted to either health care or social services and housing should and could be more routinely braided together. Despite some interesting experiments and demonstrations that allow certain health and housing money to be mixed and used creatively, budget restrictions and payment systems generally make this difficult. We could seek to agree on a mixture of legislative action on payments and budgets, and using Medicaid (Section 1115) waivers, to permit money currently available only for medical services to be used instead for housing and social services where that could be shown to improve the health of individuals in a community.

Second, we could agree on bipartisan steps to allow states to experiment with more creative approaches to alter the blend of strategies they have available to achieve improved health outcomes. Section 1332 of the Affordable Care Act (Pub L No. 111–148) is a start, since it will allow states to propose alternatives to some Affordable Care Act provisions to improve coverage and outcomes without increasing federal costs. McDonough and I agree on using 1332 waivers in this way. But a further step would be legislation to allow states to seek even broader waivers to shift money between health and social service programs. For that to happen, conservatives would have to accept increases in total spending on some social service programs. Progressives would have to accept reductions in health programs and reduce their reluctance to granting states more flexibility. Both would have to accept rigorous evaluation to determine what works and what does not.

And third, there is an opportunity for agreement on empowering intermediary institutions2 in neighborhoods, including charter and community schools, as well as health systems,3 to serve as hubs for integrated approaches to achieving health communities. That approach combines the conservative emphasis on the importance of nongovernmental institutions with the progressive emphasis on community action. Again, systematic evaluation is needed.

Hopefully there can be cross-party congressional support agreement on these themes, as McDonough notes has occurred in alternative sentencing. But it is unlikely in the election season that such themes will be seized upon by presidential candidates. In my view, that is probably good, because presidential elections are about differences, not path-breaking agreements. Better, during this election cycle, to foster positive conversations that cause such themes to be taken out of the election debates, so that they will have broad support for enactment after the Election Day dust has settled

References:

1.  Gawande. Being Mortal. New York, NY: Metropolitan Books; 2015.
2. P Singh, SM Butler. Intermediaries in Integrated Approaches to Health and Economic Mobility. Washington, DC: The Brookings Institution; 2015.
3. SM Butler, J Grabinsky, D Masi. Hospitals as Hubs to Create Healthy Communities: Lessons From Washington Adventist Hospital. Washington, DC: The Brookings Institution; 2015.

ACA’s Continuing Impact on Business

[This “sponsored content” article was published on bostonglobe.com on February 2nd.]

Six years after the Affordable Care Act (ACA) became law, U.S. health care policy and the delivery of medical services continue to undergo unprecedented change. Rockland Trust’s “Talking Business Advice Series” spoke with John E. McDonough, professor of Public Health Policy at the Harvard T.H. Chan School of Public Health, to get his take on what may lie ahead for businesses working with the ACA during this dynamic period.

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Q: You helped write the ACA. It’s an extremely complex law that even today is not fully understood by many Americans, including business owners and leaders. From a high-level perspective, where do things stand with it today?

A: Most people understand that the ACA is moving us toward universal health coverage. For the United States, the ACA is a revolution, an enormous set of changes that many see as a huge step forward and many others see as a wrong turn. Globally, however, all of the world’s advanced nations prior to the ACA already had health care schemes that, to varying degrees, met the insurance needs of their populations. So, while the ACA’s insurance expansions and reforms represent a great leap forward for the U.S., it is also true that when fully implemented by 2018, the U.S. will still have the most inefficient, wasteful, and unfair health insurance system of any advanced nation, even with the ACA reforms.

On the other hand, the ACA is also advancing an agenda of dramatic and necessary change in how medical care is delivered in the U.S. As a nation, we are now moving rapidly away from a financing system based on fee-for-service payments, (which is) a system that rewards hospitals, physicians, and other medical providers based on the quantity of services they provide without regard for the quality, effectiveness, and efficiency of those services. Because of the ACA, we are now moving quickly toward a new financing framework that rewards hospital, physicians, and providers based on the quality and value of the services they provide rather than the quantity.

Q: The public doesn’t necessarily view it in this way, does it?

A: You’re right. This change has gone unrecognized by the broad public, even as it moves forward in rapid and profound ways. A lot of what the ACA envisions is experimental. Some elements are working better than others; some continue to be fiercely debated. The U.S. doesn’t have all the answers in this effort, but we have the most dynamic set of experiments on this evolutionary path of any advanced nation on the planet right now. Health system leaders all around the world are very interested in this set of experiments and watching closely. That is something that corporate leaders, regardless of industry sector, ought to recognize, appreciate, and understand.

Q: What are some of the effects of these experiments on businesses?

shutterstock_267836885A: The immediate effects of the ACA depend on the context of the business itself. For example, the ACA’s impact is different for larger businesses with more than 50 full-time workers, companies with new responsibilities under the ACA’s employer mandate. It’s different for smaller employers and it provides some opportunities for many of them. It’s a unique new context for start-up businesses because of the health insurance marketplaces that provide new businesses with a new way to provide health insurance for their workers, enabling them to outsource their health coverage needs for themselves and their employees. And it enables all employees to get health care coverage regardless of pre-existing conditions, which was not possible in 45 states prior to the ACA.

So it’s contextual. It depends on the size and nature of the business as to whether there will be advantages or disadvantages—or both—to the Affordable Care Act.

Q: Would you expand on how smaller companies can outsource their health care responsibilities?

A: The ACA required the development of government-regulated health care exchanges (or marketplaces) across the nation. States had right of first refusal and 13 have chosen to establish their own exchanges while the rest are run by the U.S. Centers for Medicare and Medicaid Services (CMS). These exchanges offer coverage to all eligible individuals who can’t obtain insurance elsewhere, and many workers are eligible for financial subsidies to keep premiums and cost sharing affordable.

Alongside these public exchanges, new private health insurance exchanges have emerged. Unlike the public exchanges, which largely provide insurance to individuals seeking to buy non-group coverage, these private entities are aimed straight at the employer community. These private exchanges can enable employers to address their responsibilities under the ACA’s mandate to provide health insurance for their workers and do it in ways that are far less onerous for employers than in the past. It’s a way to outsource these responsibilities and to provide employees with a range of coverage choices. This is a significant change from the environment that existed prior to the ACA’s passage in 2010.

Q: How are larger businesses affected by the ACA?

A: Prior to the ACA’s passage, larger businesses were concerned about not being heavily shaped by the new law because most of these businesses already covered most of their employees. The impact of the ACA on larger businesses—especially those that self-insure—is far less than what they would experience in the standard commercial insurance market were they to go out and purchase traditional coverage.

Nonetheless, there are important new coverage requirements that impact the large employer market—whether self-insured or not. For example, lifetime or annual benefit limits on workers coverage is no longer permitted. Employer plans must cover the “essential health benefits” specified in the law. A worker’s insurance premium cannot exceed 9.5 percent of his or her household income or else the employer mandate penalty can be triggered. All employers must allow their workers to keep adult children on their family policies up to age 26. The ACA also sets a 90-day maximum waiting period before full-time workers are eligible for coverage.

There are also some elements of the law that many employers appreciate, including the ability to vary worker premiums by 30-50 percent in relation to workers’ use of tobacco products and participation in workplace wellness programs. Clinically proven preventive care services, such as mammography, must be provided to workers without any cost sharing.

The ACA’s impact is far more substantial in the traditional commercial health insurance market—but the impact on large self-insured employers is also meaningful.

Q: Are all the details of the ACA settled at this point?

A: This law is changing every day. There are at least three dozen things changing in relation to this law almost daily—in Congress, in federal agencies, in states, in the private sector—changes shaping how this law is unfolding across American society. And the pace of change hasn’t slowed, even now when we’re in the sixth year since the law was enacted.

857b31fa-2754-4722-91af-eb44dbc47690-acaThe ACA is likely to change even further next January when a new president and administration takes office, regardless of which party controls the White House and Congress. We can see an evolving agenda for changes from both sides of the political spectrum. Congressional Republicans have been united in their determination to dismantle the ACA for some time. In January, President Obama vetoed an attempt to cripple the ACA that was included in a budget reconciliation bill. The fact that this initiative passed Congress demonstrates that if Republicans control the White House, House, and Senate next January, there is a strong likelihood of significant dismantling of the law.

Conversely, if the Democrats hold the White House next year they also will have an agenda for significant changes to the ACA, though far less dramatic than what would happen under Republican control. Either way, we can anticipate some significant changes coming in 2017.

Q: How do business leaders prepare for that?

A: They need to keep abreast of whatever changes occur. Many organizations help businesses to stay on top of what’s changing or likely to change. It’s important for executives and managers who focus on a company’s health coverage to stay up-to-speed on what’s happening, and it’s important for those in the C-suite to understand the changes to factor these new variables into their strategic planning calculus.

As a nation, we are on a path of rapid and deep systemic change to our health system, and it’s going to unfold for some time to come. It is already transforming the fundamental nature of the U.S. medical care delivery system. The implications of it are vast and it will continue to unfold well into the future in positive, not-so-positive, and surprising ways.

It’s important for corporate executives to understand the nature of these changes as they happen.

The Harvard T.H. Chan School of Public Health will present a conference titled “Beyond the Affordable Care Act: The Next Frontiers for US Health Reform” on April 25-27. Visit https://ecpe.sph.harvard.edu/ for more information.