“Beyond Health Care”

The  Robert Wood Johnson Foundation’s Commission to Build a Healthier America has just released a new report: Beyond Health Care. At a time when all eyes are trained on the debate over providing access to medical care for all Americans, the report looks beyond health care, to the health of the population. As it turns out our health—public health—has less to do with health insurance than one might think.

 “Beyond Health Care” does a masterful job of pointing out that the conventional wisdom about what we need to do to improve the health of our population is blinkered.  Many pundits assume that  providing access to medical care will solve our problems. Others insist that lecturing Americans on “personal responsibility” will do the trick. The report makes it clear that the received wisdom is wrong on both counts.

 “Beyond Health Care” does a masterful job of pointing out that the conventional wisdom about what we need to do to improve the health of our population is blinkered.  Many pundits assume that  providing access to medical care will solve our problems. Others insist that lecturing Americans on “personal responsibility” will do the trick. The report makes it clear that the received wisdom is wrong on both counts.

First, the report observes that, while medical care is important, “Health is More Than Health Care”:  “Although medical care is essential for relieving suffering and curing illness, only an estimated 10 to 15 percent of preventable mortality has been attributed to medical care [or lack thereof.]  A person’s health and likelihood of becoming sick and dying prematurely are greatly influenced by powerful social factors such as education and income and the quality of neighborhood environments.”

Secondly, the report’s lead authors, the Brookings Institution's  Mark McClellan  and Alice Rivlin, acknowledge that: “Many people live and work in circumstances and places that make healthy living nearly impossible. . .Unquestionably, we must take individual responsibility for our health and the health of our families. At the same time, we must recognize that, in many instances, the barriers to good health exceed an individual‘s abilities, even with great motivation, to overcome these barriers on his or her own. In seeking a healthy society, we must consider the choices available to individuals and the contexts in which choices occur—including conditions in homes, neighborhoods, schools and workplaces—that can constrain or enable healthier living.”

Health Is More than Health Care

If you compare the U.S. to other countries, you recognize that the RWJF report is right when it declares that “More health care spending will not solve our health problems. Even with technologically advanced care for conditions such as preterm births, diabetic complications and heart disease, we cannot expect this care to close the global health gap. Infant mortality and life expectancy rates in the United States lag behind most of Europe, Japan, Canada and Australia, and in the last two decades, U.S. rankings have fallen lower on the scale relative to other nations, despite our rapid increases in spending. In 1980, the United States ranked 18th in infant mortality rates among industrialized nations. By 2002, 24
industrialized nations—including Korea, Hungary, the Czech Republic and Greece—had lower infant mortality rates than the United States.”

 As I have pointed out in the past, even when you narrow the comparison to Caucasians in the U.S. to Caucasians in other countries, the U.S. fares poorly.   Overall, the United States slipped from 14th among industrialized countries in life expectancy at birth in 1980 to 23rd by 2004. We need to look beyond medical care to other factors that can improve America’s health.

Where you live plays a major role in how well  you are.  “Many Americans do not have access to grocery stores that sell nutritious food” the report observes.  “Still other  live in communities that are unsafe or in disrepair, making it difficult or risky to exercise. While individuals must make a commitment to their own health, our society must improve the opportunities to choose healthful behaviors, especially for those who face the greatest obstacles.

“For example, members of disadvantaged racial and ethnic groups are more likely to live  . . . near toxic wastes, abandoned or deteriorating factories, freeway noise and fumes; and exposure to crime and violence and other hazards—increase the chances of serious health problems. “

Being poor also means having less control over your life, and this can be incredibly stressful. “Limited economic means can make everyday life a struggle, leaving little time or energy to adopt healthy behaviors and crushing motivation. Chronic stress associated with financial insecurity can seriously damage health, causing wear and tear on the heart and other organs and accelerating aging.

“Living in health-damaging situations often means that individuals and families don’t have healthy choices they can afford to make. Protecting and preserving good health will mean focusing on communities and people, how and where they work, where their children learn; fixing what impairs our health and strengthening what improves it. The road to a healthier nation requires us all to understand that this is about everyone, rich and poor, minority and majority, rural and urban. We cannot improve our health as a nation if we continue to leave so many far behind.”

Ultimately, the report appeals to our sense of justice, and the nation’s basic values: “This shouldn’t be the case in a nation whose highest ideals and values are based on fairness and equality of opportunity. Where people live, learn, work and play affects how long and how well they live—to a greater extent than most of us realize. What constitutes health includes the effects of our daily lives—how our children grow up, the food we eat, how physically active we are, the extent to which we engage in risky behaviors like smoking and our exposure to physical risks and harmful substances—as well as the neighborhoods and environments in which we live. We must identify where people can make improvements in their own health and where society needs to lend a helping hand..”

The Status Quo: A Relentless Search for Better Health for the Middle and Upper Middle-Classes

Reading the Robert Wood Johnson  report, I can’t help but think of Dr. Steven Schroeder’s landmark Shattuck lecture, published in the New England Journal of Medicine in  September of 2007, titled “We Can Do Better: Improving the Health of the American People.” Schroeder pulls no punches: “The comparatively weak health status of the United States stems from two fundamental aspects of its political economy. The first is that the disadvantaged are less well represented in the political sphere here than in most other developed countries, which often have an active labor movement and robust labor parties. Without a strong voice from Americans of low socioeconomic status, citizen health advocacy in the United States coalesces around particular illnesses, such as breast cancer . . . These efforts are led by middle-class advocates whose lives have been touched by the disease.”

 He continues: “To the extent that the United States has a health strategy, its focus is on the development of new medical technologies . .  . We already lead the world in the per capita use of most diagnostic and therapeutic medical technologies . . . But these popular achievements are unlikely to improve our relative performance on health.. . ”    As HealthBeat readers know, many of these advanced technologies are marginally effective --- or helpful only for a small group of people who fit a particular profile  Yet, we squander billions  applying these technologies to patients who will not benefit.

Meanwhile, Schroeder writes “the biggest gains in population health would come from attention to the less well off.”  In other words, we need to invest more money in public health, less in cutting edge technology. “But little is likely to change,” says Schroeder, “unless [the poor] have a political voice and use it to argue for more resources to  . . .  reduce social disparities . . .”

He is not optimistic that this will happen: “It is arguable that the status quo is an accurate expression of the national political will — a relentless search for better health among the middle and upper classes.”           

Poverty in the U.S. and Other Developed Nation

 “But," Schroeder asks, "aren't class gradients a fixture of all societies? And if so, can they ever be diminished?”  In other words, won't the poor always be with us?

We don't have to tolerate the degree of inquality that we see in the U.S. today.  "“The fact is that nations differ greatly in their degree of social inequality and that — even in the United States — earning potential and tax policies have fluctuated over time," Schroeder points out, "resulting in a narrowing or widening of class differences. “

In the 1950s and 1960s, socio-economic gaps were much narrower among white Americans.  This is in part because absurd CEO salaries (which came into vogue in the 1980s,  along with Celebrity CEOs smiling out at you from magazine covers. ) had not yet set a multi-million-dollar standard as to what it means to be “well off.”  Soon, other professionals began to feel that if they weren’t earning at least $750,000 --and preferably something closer to $2 million -- they were falling behind in the scramble for fame and success.  Stockbrokers, divorce lawyers, baby bankers,  real estate brokers,  interior designers, and TV pundits all judged themselves miserable failures if they couldn’t command high six-figure incomes.

In the 1950s and 1960s a very different tax policy also promoted greater economic equality. Today, few remember that in 1945, the marginal tax-rate on individuals earning over $200,000 was 94%. It stayed over 90% until 1964 when it was lowered to 77%.  (Note: in 1960, $200,000 was worth roughly $1.4  million in today’s dollars. And  of course a “marginal rate” is what a taxpayer laid out for every dollar over $200,000—he was not paying  90% on the first $200,000.)

When President Reagan came to office in 1980, he began slashing tax rates for the wealthy. By 1988, the tax on the top tier hit a low of 28%.

In the early 1990s,  President George H.W. Bush realized that more money was needed to run the government, and he did the only thing that made sense at the time--he raised  taxes to 31% --despite campaign promises not to do so. By then, the wealthy had become accustomed to Reaganomics—an economic policy that had the effect of redistributing wealth upward-- and they punished Bush Sr. for the 3 point raise by voting him out of office

What most people do not realize is that while the very wealthy have been paying relatively low taxes since the 1980s, historically this is an anomaly. During much of the twentieth century the top rate was far higher. During the Great Depression, ,money was needed, and those who could afford it paid 63%. After World War II started, the tax rate skyrocketed—and, as noted, remained high in the decades that followed.

The chart below shows  the top marginal rate for the wealthiest 1 percent from 1944 to 2005--  and an even more important number, the top effective rate (the share of their income that people in a particular bracket actually wind up paying in taxes, after taking advantage of whatever deductions and legal loopholes are available to them. You can see how taxes suddenly plummeted in the 1980s.  Today, the top marginal rate remains around 35%-- down from over 75% in the 1950s and 1960s--and the effective rate is a little lower. (The numbers behind the chart come from the Congressional Budget Office

“The taxes paid by those at the top matter a great deal for government finances” notes Lane Kenworthy, a professor of political science and sociology  at the University of Arizona.   On  his blog “Consider the Evidence,” Kenworthy writes: “As of 2005 the top 1%  accounted for 28% of federal government tax revenues. That isn’t because they are taxed at an outlandish rate,” he adds. “An effective tax rate of 30-40% is hardly confiscatory. Instead, it’s because they get a very large share of the country’s income — 18% as of 2005.”  Think about it: the wealthiest 1 percent salt away close to one-fifth of all income.

In a future post, I will discuss what share of taxes affluent, but not super-rich Americans (households earning over $150,000) pay when compared to those who earn less than $150,000; the myth that higher taxes lowers productivity;  the correlation between better health and the higher taxes paid in other developed countries , and what the Robert Wood Johnson Foundation recommends as a remedy to lift the health of all Americans.