We have remained fixated for a century or more on the notion that health policy is essentially health care and insurance policy. – James House
The continuing conundrum of health and health care in the US is how much we’re spending on health care (highest in the world – almost $10K per capita and 16% of our GDP) and how poor our health is (generally 25th to 30th among the 35 OECD countries on a variety of indicators, and the absolute worst in terms of obesity).
In my last post, I noted “the developed world seems to have lost the thread on public health and health care. In the US, it’s all about the money – who pays, the role of insurers and holding costs down. While I don’t mean to downplay the role that money plays, the political debates have distracted us from what should be our focus: healthy people in healthy communities. Communities need healthy hands to build or rebuild themselves. Health care as practiced in the developed world is the human equivalent of rebuilding damaged infrastructure. But Wellness is equally important to individual, family and community resilience; just as is building robust infrastructure.”
Since I wrote that, I’ve been digging into the subject of health and health care. I’ve been starting from the goal – healthy people, rather than focusing on health care. This makes sense because if we look at the determinants of health, health care is only one of them and less important than others – about 10%. Lifestyle factors (individual behavior, social circumstances, environment) collectively are much more important – 60 – 75%, with individual behavior (40-50%) the greatest single determinant of health. The other major health determinant is genetics (20 – 30%).
During my time in Mississippi (at the time, the poorest state in the nation), I frequently participated in a sort of ritual that illustrates the importance of behavior. Whenever I went into a small town and met someone new, the first thing that person would do is ask me where I was from and then play the Mississippi version of the “Kevin Bacon Game” – who did I know who they knew; who did they know who I knew. Once they had me “placed,” invariably the ritual would lead to an invitation to eat with them – a piece of pie, cookies, sweet tea – whatever they had. It should be no wonder that Mississippi usually has the nation’s highest incidence of diabetes and the complex of diseases that it leads to.
Of course, if they had access to good health care these diseases could be treated. But many who live in rural communities don’t. If we were to pay attention to only the politicians and the pundits, at this point they would begin to prattle about the importance of insurance, and about who pays for health care, maybe a word or two about a single payer health system. But paying for it isn’t what’s limiting access to health care in rural America; it’s simply that health care facilities are disappearing from the rural landscape.
But from the standpoint of our communities, we need to focus on the desired outcome – a healthy population, and not just on one of its determinants – health care. And that focus should be through the lens of our communities – the control knobs we can turn at the community level so that we, our families and friends can live healthy lives.
Sadly, poverty and ill-health go hand in hand. Too many of the poor live in food deserts and so do not have proper nutrition. Too many of the poor are isolated from their communities, especially the elderly. Too many of the poor are battling severe mental health issues that manifest themselves in drug use, suicide or – especially for the young – gang violence. And let me make it clear that it’s poverty – not inequality – that’s the problem.
The best way to sustainably overcome poverty is to provide opportunity for everyone in the community to maximize their potential – that means jobs. Inequality is a natural state; somebody is always going to be stronger, smarter, faster, richer… Trying to prevent inequality is like old King Canute trying to hold back the tide. But what we can do is aim for communities that have ladders for everyone to climb as far as they can, and floors so that no one can fall too far.
If we look at the determinants of health I mentioned above, it should be apparent a healthy citizenry depends on many players working together – not just health care, but public health, parks and recreation, transportation and, of course, the economic engines of the community. If our communities are going to be healthy that means effective governance across all of these domains achieving healthy outcomes.
The importance of effective governance is magnified in rural America because one community is unlikely to have the resources to go it alone. That means regional governance and, possibly, the involvement of state government. We are already seeing some interesting successes, e.g., in Allen County, TX. I’m hoping that these will have a great deal to teach us about how to make collaborative decision-making and implementation work better in urban settings as well.
Ultimately, our communities are about people. Healthy communities require healthy people; health care plays a role, but probably not even the most important. When we allow our discussions of health to degenerate into squabbles about who pays for health care we’re missing the bigger picture. Parks, ball fields and greenways are far less expensive and certainly as important as health care for a healthy community. Clean water and air, jobs and reaching out to each other – all are important determinants of a community’s health. Our media’s microscopes are narrowly focused on the politics and can’t see what is really important: healthy communities rely on healthy people to sustain their resilience.
PS. An important stimulant for my thinking on health and health care has been ReThink Health, an initiative of the Rippel Foundation. They recognize that since change requires time, the financing of change must be sustainable. And they recognize the importance of governance, because so many organizations and types of organizations are involved in a community’s health.
Editor’s note: This blog was originally published by the Community & Regional Resilience Institute (CARRI) and has been reposted with permission from the author. To learn more about CARRI, visit www.resilientus.org