Thursday, July 02, 2009

Health care access and results

Theory: health is a product of availability to health care. Expand access to health care -- such as through a single payer or universal coverage system -- and we will have healthier people.

But is it true? Here is an excerpt from a paper published by the Journal of Personality and Social Psychology:
Prominent among the challenging facts is that the paradigm’s key health resource — greater access to medical care—has surprisingly little relation to differences in health. The introduction of Medicaid and Medicare in the United States during the 1960s soon led to the poor making as many physician visits per year as the nonpoor, but large class differentials in health remained — even when the poor began to visit physicians at a higher rate than the nonpoor (Rundall & Wheeler, 1979, p. 397).

Great Britain and other countries that had expected to break the link between class and health by providing universal health care were dismayed when the disparities in health not only failed to shrink but even grew (see The Black Report by Townsend & Davidson, 1982; also Link & Phelan, 1995, p. 86; Marmot, Kogevinas, & Elston, 1987, p. 132; Susser, Watson, & Hopper, 1985, p. 237).

It is now amply documented, first, that equalizing the availability of health care does not equalize its use. Perhaps most important, less educated and lower income individuals seek preventive health care (as distinct from curative care) less often than do better educated or higher income persons, even when care is free (Adler, Boyce, Chesney, Folkman, & Syme, 1993; Goldenberg, Patterson, & Freese, 1992; Rundall & Wheeler, 1979; Susser et al., 1985, p. 253; Townsend & Davidson, 1982, Chapter 4).

Second, greater use of medical care does not necessarily improve health (Marmot et al., 1987, p. 132; Valdez, Rogers, Keeler, Lohr, & Newhouse, 1985). To illustrate, when a large, federally funded, RAND-conducted, randomized controlled experiment tested the effects of subsidizing health care costs at different levels in six cities across the United States, participants with free care used more medical care than those with only partly subsidized care, but their health was no better after 2 years. Participants with free care had indiscriminately increased their use of inappropriate as well as appropriate care (Lohr et al., 1986, p. 72). Prenatal care provides another example that more care does not necessarily produce better outcomes, in this case for newborns (Fiscella, 1995).

Third, health depends more now than ever on private precaution and health lifestyle. The American Psychological Society (APS) noted in its 1996 Human Capital Initiative report on health (APS, 1996) that “seven of the 10 leading causes of death have aspects that can be modified by doing the right thing; that is, by making healthy choices about our own behavior” (p. 5) and that mortality “could be reduced substantially if people at risk would change just five behaviors: Adherence to medical recommendations (e.g., use of antihypertensive medication), diet, smoking, lack of exercise, and alcohol and drug use” (p. 15).

It went on to describe how “doing the right thing” not only helps prevent the onset of disease, but also can “reduce the pain and progression of some diseases” and “determine whether the illness will be devastating or whether quality of life can be preserved or extended” (p. 9).
Many more interesting thoughts about health care on this blog post.

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