This Health Affairs blog post is irritating, though not because it’s wrong. In the blog post, the authors acknowledge the following facts:
- Health care services do not account for more than 15-20 percent of population health outcomes (Ed: AT MOST)
- The vast majority of Americans believe that health is largely a function of access to health care services
- The vast majority of cost-effectiveness research is done on health care interventions (i.e., in the clinical sector)
These points, and others like it, are the empirical jump-off points for my own work, which essentially pleads with scholars and policymakers alike to invest their attention and resources to the prime determinants of health and its distribution (the social and economic conditions in which people live, work, and play).
I suppose what irritates me most is that health policy experts in the US spend the vast majority of their time on HSR and health insurance. These paradigms are important and worthy of attention. But given the overwhelming evidence that HSR and access to health insurance are not the prime determinants of health and its distribution, this allocation of time, energy, and attention seems misdirected. And I charge health policy experts with knowing this, which makes their overwhelming focus on health care and access to it all the more frustrating. The authors of the blog post briefly address the causes of this focus:
Given the large spend in the health sector, health services researchers and economists understandably gravitate to clinical interventions to investigate where greater efficiency and effectiveness can be found. And because so much money is invested in medical care and the research that underpins it, such studies are comparatively easy to undertake. Meanwhile, the evidence base is much less straightforward when it comes to analyzing the cost-effectiveness of interventions that target more broadly health-beneficial policies, those that through tax policies promote and inhibit health-affecting behaviors, those directed at built and natural environments, education, and other strategies that directly or indirectly affect people’s health.
Priority-setting matters. And we spend far too much time talking and arguing over things and phenomena that IMO do not justify the moral priority we seem to grant them. Even the terms of our debates reflect this, as in the pharmaceuticalization of health (to where people on all sides of the debate frame health in terms of access to drugs). The blog post reflects this — it is not simply the actual proportion of expenditures on health care vs. whole population interventions (which is hard to quantify but according to several measures, public health spending in the US is rarely more than 3% of overall health expenditures) — but even our attempts to analyze health and the welfare state fall prey to the Health Care Beast. (The authors’ point is that we do most of our CEA on clinical interventions and health services, as opposed to whole population interventions targeted at root social determinants).
Although I generally agree with the blog post, I’d also note we do have some excellent CEA on some upstream interventions, such as the phenomenal work on The Abecedarian Project. The ROI is so good for the kind of intensive early childhood intervention evaluated here, Nobel laureate James Heckman has made such investment a cornerstore of The Heckman Equation.
Finally, the HA blog post leaves unaddressed what to my mind is the crucial question: does the evidence base we do possess as to the social determinants of health sufficient to justify public health action? Or need we wait until we have broader and perhaps more rigorous cost-effectiveness research as to root social determinants?
I think the evidence is more than sufficient to justify action, at least in some paradigms and as to some interventions, and a significant portion of my work is devoted to justifying this conclusion.