Health care policy vs. health

Why are politicians allowed to put forward “health” proposals that focus entirely on health care finance? And why are progressives in particular seemingly indifferent to the rate of progress in our ability to prevent and treat disease?

Update Matt Yglesias points to an extended essay on this point by Phillip Longman.

It’s that time of campaign again, and candidates are coming forward with their health policy proposals. Predictably, those proposals are almost entirely about health care, and in particular about health care finance. That means they neglect many of the high-impact, low-cost ways of making the population healthier and longer-lived. And while Democrats are enthusiastic about innovation in health-care delivery through the use of information technology, their plans seem strangely indifferent to the impact of the financing changes they propose on the pace of innovation in the technology of preventing and treating disease.

Of course health care and health care finance matter. The crazy way we pay for health care in this country imposes enormous risks on individuals and households, bankrupts businesses, distorts labor-market choices, and wastes a ton of money. Caring for the sick is one of the distinctive features of human beings as a species, so it’s not surprising that access to high-quality care is an emotionally compelling social issue. But there’s something wrong when a politician can issue a plan to deal with health that ignores all the non-medical-care policies that contribute to good and ill health.

If we’re genuinely, as well as symbolically, concerned with the health of our neighbors, then the current fixation on health care access misses the mark.

Preventing the costs of health care from ruining families, bankrupting businesses, and distorting job decisions is an important objective. And enabling people to live healthier and die later is also an important objective. But improving access to, and the quality of, medical care is only a second-order objective. It’s surely not the most cost-effective way of reducing morbidity and mortality.

Air quality improvement, noise reduction, better parenting practices (which we can purchase publicly with nurse home visitation programs) and changes in the social forces influencing diet and exercise all probably have greater bang for the buck. Compared to getting the lead out of gasoline, everything else that happened in the 1980s to influence the health of children was rounding error. How expensive would it be to get school cafeterias to serve healthy means that tasted good? It’s hard to blame kids raised on boiled vegetables at home and at school for thinking vegetables are icky; boiled vegetables are icky, and not actually nutritious. Or exercise: how much could an upgrading of the corps of “physical education” teachers, and extending the school day to allow more running-around time, do to reverse the trend toward couch-potatoism?

Yes, it would be hugely useful to have a public-private-academic effort to help speed the spread of evidence-based medicine. But as bad as current knowledge and knowledge distribution about drugs, devices, and procedures now is, knowledge and knowledge distribution about diet and nutritional supplementation is far, far worse, with so much quackery in the marketplace that it’s extremely difficult for a non-scientist to get accurate information about whether any currently sold product is likely to retard the normal cognitive decline with aging, and if so which one or ones and what their side effects are. (A very smart guy I know swears by the commercial food preservative BHT. For all I know, he could be right.) Recapturing the “alternative and supplementary medicine” office at NIH from the nutritional-supplement lobby wouldn’t cost any money at all, and might make a difference. As far as I know, there’s never been a well-controlled experiment on whether an hour a week of massage therapy improves health outcomes in healthy normals. Shouldn’t we know?

Given the poor record of, for example, efforts to lose weight, it’s easy to dismiss lifestyle interventions as too hard. Some are, some aren’t. Parts of human behavior are mysterious, but we know lots of things that matter. Price matters; if alcohol and tobacco cost more, people use less of them. Availability matters; the “war on drugs” hasn’t eliminated drug abuse, but we have 2 million cocaine (including crack) abusers and 15 million alcohol abusers largely because alcohol is legal and heavily marketed. Fashion matters; people do what they think is expected of them, and what they see done by people they aspire to resemble. I don’t know how to get an individual to lose weight, or even how to lose weight myself. But changing the relative price and availability of healthy and unhealthy foods would change the overall nutritional pattern.

I don’t think that we ought to run our whole social system for the sole purpose of preventing disease. And of course people get sick even if they live healthy lifestyles. My claim is that the next billion dollars spent on changing the social conditions that lead to unhealthy living will do more to increase lifespan and decrease illness than the next billion dollars spent on physicians’ services, and that a politician can come forward with a “health” plan that concentrates entirely on services.

The problem is to rescue this set of issues &#8212 all the lifestyle, nutritional, and environmental contributors to health &#8212 from the public-health authoritarians on the one hand and the commercial, new age, and “deep environmentalist” quacks on the other. Health isn’t the only thing that matters, but health matters, and encouraging people to maintain their own health rather than relying on the medical-care system to fix the consequences of neglect ought to count as a major social objective.

Within the world of drugs and medical care, increasing the pace of innovation ought to be a central issue, not a peripheral one. Making the terms of the efficacy/cost/side-effects tradeoffs better is something we ought to care about, especially given that the work done in the US now potentially benefits the whole world now and later. I know “innovation” is the battle-cry of those opposed to cost containment, but that doesn’t mean that we (progressives especially, I would have thought) can afford to ignore it. We’re in the midst of the Golden Age of biology; our ambitions for improving the way we prevent and treat disease should be correspondingly sweeping. And (if I may ride my personal “new age” hobby-horse) we need to redefine the topic of innovation away from a sole focus on the cure of identified disease entities toward improving overall functioning, including by making people “better than well” where possible. It’s not natural for an 85-year-old to be as sharp as he was at 25, but it may well be feasible, and we ought to be spending real money finding out how.

If focusing exclusively on current cost, quality, and access means accepting a slower pace of health-care and wellness-enhancement innovation, I think that’s a bad trade. In economic terms, much of our current health care spending is in fact investment in new knowledge and new ways to apply it. If the choice is between spending money on physical capital and spending money on practically applicable biological knowledge, I bet biomedicine has a higher rate of return in welfare terms.

The goal of getting the health care system to stop eating the economy remains, but in that domain I’d focus on buffering risk and reducing perverse incentives, not on reducing the share of health care in GDP. In a country that continues to get richer and richer in material terms, there may not be anything many families could spend the money on (aside from more cost-effective means of health promotion) that would improve their lives as much.

Author: Mark Kleiman

Professor of Public Policy at the NYU Marron Institute for Urban Management and editor of the Journal of Drug Policy Analysis. Teaches about the methods of policy analysis about drug abuse control and crime control policy, working out the implications of two principles: that swift and certain sanctions don't have to be severe to be effective, and that well-designed threats usually don't have to be carried out. Books: Drugs and Drug Policy: What Everyone Needs to Know (with Jonathan Caulkins and Angela Hawken) When Brute Force Fails: How to Have Less Crime and Less Punishment (Princeton, 2009; named one of the "books of the year" by The Economist Against Excess: Drug Policy for Results (Basic, 1993) Marijuana: Costs of Abuse, Costs of Control (Greenwood, 1989) UCLA Homepage Curriculum Vitae Contact: Markarkleiman-at-gmail.com