Don’t confuse health care reform with public health
Among the many exaggerated claims made in favor of the health care legislation before Congress is the idea that it would improve the public health system’s ability to manage public health crises like HIV and swine flu.
Unfortunately, public health and health care are different issues, served by overlapping but separate systems. Expanding access to health care does not necessarily lead to gains in public health.
The idea that health care contributes significantly to population health is both intuitively appealing and untrue. Nowhere is this better seen than in the improvement in infectious disease mortality during the 20th century, which was due primarily to non-medical advances, including progress in water and sewage treatment, food safety, insect control, housing, and income. Roughly 75 percent of the improvement occurred before medicine made a serious contribution with the introduction of effective antibiotics in the early 1940s.
Essentially all of the improvement happened before widespread use of childhood vaccines in the 1950s and 1960s. The current health care legislation includes no mechanisms to improve or expand on such broad-based prevention programs.
The primary responsibility for public health, moreover, resides with state governments. Federal agencies such as CDC lack the ability and authority to provide top-down control of the public health system, for both constitutional and practical reasons.
The “police power,” or the ability to regulate common nuisances that threaten a population, is reserved by the Tenth Amendment to the states. Binding policy and implementation decisions are made by state governments, and generally implemented by local health departments, both of which are focused on local concerns. The federal government is largely limited to a supporting role, like assisting with disease investigations or conducting research.
And that’s a good thing. Knowledge of and responsiveness to local needs is an advantage in public health, where local problems vary widely. A county in the Mississippi Delta is likely to be concerned with obesity caused by poverty, while a county with an Indian reservation may see alcohol abuse as a bigger issue. There exists little evidence that federal categorical grants, such as the recent influx of money through the bioterrorism preparedness program, change local priorities in a way that improves population health.
In fact, federal “reform” often hurts the public health system. Both public health and health care experts have criticized Medicare and Medicaid, enacted by Congress in 1965, for changing the focus of health care practitioners from prevention to treatment. Infectious disease mortality rates rose 22 percent in the 1980s (even after discounting for AIDS deaths), despite rising public and private spending on health insurance and medical care. In 1988, the Institute of Medicine warned of a deteriorating public health system. Inadequate vaccine supplies, such as the recent shortages of the measles-mumps-rubella vaccine or influenza vaccines, are at least in part the result of federal attempts to control the production and distribution of the vaccines.
Requiring all Americans purchase health insurance, which the current bills hope to do, would not address the underlying socio-economic issues at the root of most public health problems. Income, social capital, employment status, and other factors have a stronger impact on population health than access to health care. People with more education and higher incomes are better able to avoid health risks. Poor children have higher levels of blood lead precisely because they live in older dwellings more likely to contain lead-based paint.
Indeed, access to health care can help individual patients, but can also aggravate some public health problems. Healthcare, like everything else in life, involves risk tradeoffs. Hospitals can help cure disease, but by their very nature can also help spread infections. Most of Toronto’s 2002 SARS cases were infected, for example, were health care workers and visitors infected by exposure to the virus in a hospital. High rates of surgical intervention increase the risk and spread of drug resistant infections like MRSA.
The current legislation would address none of these issues. In fact, its high cost, estimated at $2.5 trillion in decade after full implementation, could aggravate these issues by damaging the economy.
It would be nice if subsidizing private health insurers could somehow rebuild our damaged public health infrastructure. But such claims should be taken with more than a grain of salt.
George Avery, Ph.D., MPA, is an assistant professor of public health at Purdue University, and the author of “Scientific Misconduct: The Manipulation of Evidence for Political Advocacy in Health Care and Climate Policy” (Cato Institute).