Health outcomes in the US – is it all about access?

By Taruni Roy Khurana and Cynthia Ayris Kemp

For anyone following the Presidential election primary debates, there is no doubt that healthcare resides at the forefront of these discussions. Though they differ on the specifics, all candidates want to improve access to healthcare. The spectrum of policy solutions ranges from abolishing all private insurance and having a single-payer system to smaller, incremental steps towards Medicare for All or a hybrid of public and private options.1 

One thing is clear – the U.S. health care system is broken, and we need change.  Even though the U.S. spends nearly twice that of comparable countries in per capita health care costs, our health outcomes are worse.  Pregnancy-related deaths have been increasing in the U.S. while declining in other comparable countries.2 Our rates of obesity3 and premature deaths and disabilities due to substance abuse-disorders are amongst the highest.4 Furthermore, the average life expectancy in the US is lower than that in any other comparable country.5   

Access to care is certainly one possible explanation for the gap between health outcomes.  According to the Kaiser Family Foundation, 99.9% of the populations of comparable countries are covered by public or private health insurance.  By contrast, the U.S. has the lowest insured rate of our peers, with 91% of the U.S. population covered by public or private insurance in 2016.6  

A second explanation could lie in the quality of care received. However, it is challenging to measure the quality of health care systems. One method to assess the quality of health care compares the rates for deaths considered preventable with timely and effective care, a concept captured by the term “amendable mortality.”  As measured by the Healthcare Access and Quality Index, the U.S. has poorer rates of amendable mortality than any other comparable country.7  

The body of evidence around a third possible explanation – the social determinants of health – is growing. The social determinants of health refer to the upstream, nonmedical economic, societal and environmental factors outside of the health system that influence health.  Certainly, health disparities can parallel income disparities, though the relationship is complex and sometimes bidirectional with poor health leading to an inability to work which, in turn, lowers income level. Measured by the Gini coefficient, the U.S. has the highest income inequality of any comparable country.8  

However, any single number representing the health outcome status of an entire nation can hide many stories. For instance, on average, does every American live for a shorter time compared to people from other wealthy nations? Or is it that some groups of Americans live longer than average, and others have a substantially shorter lifespan? Do people fall in these groups randomly or is there a systematic assignment to either of the two groups?

Answers to some of these questions can be found in a comparison of two suburbs of Kansas City that are separated by three miles – Armour Hills and Blue Hills. If you were born in Armour Hills, your life expectancy is 83 years of age.  Compare this to an average life expectancy of only 70 years for someone born in the Blue Hills area.9  Understanding the social determinants of health helps explain the 13-year discrepancy in life expectancy in three short miles.    

Research from the Institute for Health Equity suggests that a significant portion of this gap can be explained by the inequitable differences in the conditions in which people are born, grow, live, work, and age.  These social determinants of health are shaped by the distribution of money, power and resources and include factors like education, health care systems, access to healthy food, community and social context, neighborhood and physical environment, and economic stability.10  

Returning to our example of Kansas City, consider the following statistics for Armour Hills and Blue Hills.   The median household income for Armour Hills is $103,000, the unemployment rate is below 5%, and 70% of the residents have a college degree. Contrast this to Blue Hills where the median household income is about $30,500, unemployment rates are very high, and less than 50% of the residents have a college degree.11 

The figure below illustrates the socio-economic factors which are critical in determining something as basic as the lifespan of an individual.  Research has shown that higher levels of education are strongly correlated with better health and that poverty limits access to healthy food and safe neighborhoods, , .12, 13, 14 For instance, children whose parents have not finished high school are more likely to have reduced access to quality living spaces and recreational spaces like parks and libraries.15 Furthermore, these detrimental effects on their health can last for multiple generations.16 

 

There are many theories but no clear evidence on the mechanisms of how the social determinants of health affect population health. However, there is no doubt that addressing social injustices and health inequities which are paramount to improving the health of Americans will be a long, arduous road.  But Sir Michael Marmot, considered a leading expert on the topic, offers a roadmap for the journey towards a more equitable society with recommendations in six domains, including17:

  • “Providing children with the best start in their early childhood” 

Parenting decisions have been shown to have a strong correlation with social and cognitive development in young children.18 National policies that support parents and other caregivers for children can have long term beneficial effects for the whole life course of an individual. 

  • “Enable all children, young people and adults to maximize their capabilities and have control over their lives” 

National policies to ensure that quality education and work skills are available to everyone across the social gradient are critical.

  • “Create fair employment and good work for all” 

This would require the creation of sustainable jobs opportunities that ensure a minimum standard of living for everyone across the social gradient. This is especially important for people from marginalized groups – including people with mental illnesses, ethnic and sexual minorities, caregivers, older people, people with limited or no skills, and young people. 

  • “Ensure a healthy standard of living for all”

As nations become wealthy, the minimum income required to maintain a healthy lifestyle also increases. Thus, it is important to establish a national minimum wage that would ensure healthy living for people of all ages across the social gradient. 

  • “Create and develop healthy and sustainable places and communities” 

Programs that promote social links within and between communities at the local level will ensure ownership and resilience at the individual level. 

  • “Strengthen the role and impact of ill-health prevention”

Investments in prevention strategies for health in the early years of an individual’s life can change the health behaviors and outcomes later in life. 

The complex problems behind the social inequities driving health inequities require complex solutions. We must begin with the will to change and a vision for both small, incremental steps and large-scale initiatives, to dramatically affect the lives of many. We hope that one day, the short walk between Armour Hills and Blue Hills in Kansas will no longer mean a difference of 13 years of life!

Sources
  1. https://www.washingtonpost.com/graphics/politics/policy-2020/medicare-for-all/
  2. https://www.healthsystemtracker.org/indicator/quality/maternal-mortality/
  3.  https://www.healthsystemtracker.org/indicator/health-well-being/body-mass-index-bmi/
  4. https://www.healthsystemtracker.org/indicator/health-well-being/substance-abuse/
  5. https://www.healthsystemtracker.org/indicator/health-well-being/life-expectancy/
  6. https://www.healthsystemtracker.org/indicator/access-affordability/percent-insured/
  7. https://www.healthsystemtracker.org/chart-collection/quality-u-s-healthcare-system-compare-countries/
  8. https://www.healthsystemtracker.org/brief/a-comparison-of-social-determinants-in-the-u-s-and-comparable-countries/
  9. Human Resources and Services Administration
  10. https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/
  11. https://www.hrsa.gov/enews/past-issues/2019/may-2/life-expectancy-gap-illustrates-disparities
  12. Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Affairs 2002;21(2):60-76
  13. Walker RE, Keane CR, Burke JG. Disparities and access to healthy food in the United States: a review of food deserts literature. Health & Place 2010;16(5):876-884.
  14. Saegert S, Evans GW. Poverty, housing niches, and health in the United States. Journal of Social Issues 2003;59(3):569-89.
  15. Gopal K. Singh, Mohammad Siahpush, and Michael D. Kogan, “Neighborhood Socioeconomic Conditions, Built Environments, and Childhood Obesity,” Health Affairs 29, no. 3 (March 2010):503-512, doi: 10.1377/hlthaff.2009.0730.
  16. Raj Chetty et al., “Where is the Land of Opportunity? The Geography of Intergenerational Mobility in the United States,” The Quarterly Journal of Economics 129, no. 4 (Sept. 14, 2014): 1553-1623, doi: 10.1093/qje/qju022
  17. http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review/fair-society-healthy-lives-full-report-pdf.pdf
  18. Kelly, Y., Sacker, A., Del Bono, E., Francesconi, M., & Marmot, M. (2011). What role for the home learning environment and parenting in reducing the socioeconomic gradient in child development? Findings from the Millennium Cohort Study. Archives of Disease in Childhood96(9), 832-837.
Health outcomes in the US – is it all about access?
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