Conference: Beyond Health Insurance

The Institute of Government & Public Affairs at the University of Illinois and the University of Illinois at Chicago College of Medicine are sponsoring a conference Nov. 15-16, 2007 in Chicago entitled Beyond Health Insurance: Public Policy to Improve Health.

While I cannot find it on the web, the explanatory paragraph I received via snail mail intrigued me:

While much of the recent health policy debate in the U.S. has centered on the availability of insurance coverafe, the link between insurance and health is weak.  Insurance alone is unlikely to significantly improve health or narrow the health disparities within the population and many of the major causes of poor health such as smoking, obesity, and physical inactivity are not affected by health insurance.  This conference will present important research that goes beyond insurance to identify policies that improve health.  Sessions will focus on reducing racial and ethnic health disparities, preventing disease and promoting good health, developing and regulating pharmaceuticals and consumer information.

These are important, oft-overlooked points.  The assumed imperative for access to care is that it will improve population health.  I agree with the arguments above that this imperative is not supported by robust evidence.  A particularly interesting exchange on this was contained in the March 2007 Hastings Center Report, which featured a fascinating article by Gopal Sreenivasan regarding Daniels, Kawachi, and Kennedy's claims regarding income inequality and health distribution.

Readers of this blog know that I am a huge fan of Daniels et al.'s work, and believe that it has not yet received the traction it deserves in policymaking circles, at least.  Yet Sreenivasan asks an important question: if it is the case that (1) there exists a robust correlation between SES disparities and population health; and (2) there exist plausible causal hypotheses as to the relationship in #1; then (3) why should increasing access to care take precedence as a policy proposal over reducing SES disparities?

Daniels et al. use the two above premises as a basis for arguing that commitments to Rawlsian justice require universal coverage.  But, Sreenivasan asks, what reason is there to believe that doing so will have a greater impact on population health than simply implementing policies directly designed to reduce SES disparities?

Daniels briefly responded to Sreenivasan's critique in the same issue, but I look forward to reading Daniels' forthcoming book for a fuller and more thorough response.  In any case, this discourse goes directly to the heart of the Conference description above.

My own personal view is that the practical importance of universal coverage in terms of its impact on health is often either assumed or dramatically overstated.  I tend to think there are several areas of public health policy that may have a far greater impact on mortality and morbidity than ensuring access (e.g., reallocating funds to public health and preventive medicine, reducing health disparities, etc.).

The real imperative for enhancing access to care lies at the moral level, IMO.  The fact that so many lack access to basic medical care -- let alone preventive care -- says something profound about the culture that tolerates such a situation.  Even if it is the case that increasing access will have only a small impact on overall health, that is a descriptive claim, and says nothing about whether we ought to increase basic access as a normative matter.  Indeed, I will say that it personally affects me a great deal that I share in a culture and a society which permits so many of its least-advantaged members to go without any means of guaranteeing care.  It is because I follow Arrow in thinking that health care is not a commodity like orange juice or widgets that I find it so ethically unconscionable that so many underprivileged persons lack access.

But I wonder whether the rhetoric utilized in the health policy debate on access would be more likely to be successful (a possibility I remain sadly quite dubious of) if it took greater care to disentangle the descriptive and normative bases for universal coverage.  Doing so might also help to shed more light on public health policies that are often ignored in context of the greater access-to-care debate, even while there are compelling reasons for thinking they might have a greater impact on health than universal coverage policies would.

Thoughts?

Comments

[Frank]

"why should increasing access to care take precedence as a policy proposal over reducing SES disparities?"

Well, I think it has to do with the degree of sympathy you can expect from people. Everyone knows they're going to be sick some day, and most AMericans probably won't have enough money to pay for care by themselves.

By contrast, any policy to increase taxes simpliciter can easily be characterized negatively.

A final point--I guess that perhaps people's goal is not to maximize "health" (or life expectancy, etc) as it is to avoid being in a situation where they are denied care that most others routinely get.

[Daniel Goldberg]

Oh, I agree completely, but I tend to think your answer goes to the descriptive question (why do we favor policies increasing access to care) over the normative (why should we favor policies increasing access to care over policies designed to reduce SES disparities).

Of course, there's nothing that says we cannot do both at once, but it's also clear that the former enjoys a much higher relative priority than the latter.

In any case, I think the compelling case exists at the ethical level: it simply does not feel right to so many that they or such a substantial percentage of persons lack access to care. And I agree with that intuition wholeheartedly.