THE TREATMENT APRIL 26, 2009
is a public health policy researcher at the University of Chicago's
School of Social Service Administration, where he is faculty chair of
the Center for Health Administration Studies. He is a regular
contributor to The Treatment.
The term “health reform” means so many things to so many people: Controlling health care costs, improving quality and cost-effectiveness, stabilizing local, state, and federal public budgets, protecting patients against catastrophic financial loss, covering the uninsured, and more. Oh yeah, one more thing: Will it actually make us healthier? I and others--for example, Ezra Klein--complain that the process becomes so focused on the mechanics of healthcare financing that policymakers neglect countless opportunities to improve public health. This was true, for example, in the welcome but unimaginative stimulus package that--for obvious political reasons--poured money into advanced cancer research while slighting vastly cheaper cancer prevention interventions.
In general, we would be wise to pay greater attention outside the medical care system, to examine different strategies that improve human health. At most moments in human history, social and economic determinants have been vastly more important than medical care in explaining both the level and the variations in human health. A classic 2008 treatise, Making Americans Healthier, edited by Robert Schoeni, James House, George Kaplan, and, um, me, addresses this theme.Yet it’s wrong and lazy to be completely cynical, too. The Institute of Medicine, among others, has identified many pathways through which the lack of health insurance kills thousands of Americans every year. Cancers are discovered late. People delay seeking emergency care and mental health services. The list goes on.
And while it’s hard to predict exactly how universal health coverage might improve public health, a new paper in the Annals of Internal Medicine offers some important clues. Four top health services researchers--J. Michael McWilliams, Ellen Meara, Alan Zaslavsky, and John Ayanian--analyzed recent data from a large, nationally representative survey called the National Health and Nutrition Examination Survey (NHANES). NHANES is a remarkable resource because it includes clinical examinations performed on thousands of people every year. One can therefore measure health with actual blood test results and other clinical measures, rather than the usual clunky measures based on peoples’ fuzzy self-reports. McWilliams and colleagues examined trends in blood pressure control among hypertensive adults, glycemic control among diabetic adults, and cholesterol control among adults with cardiovascular diseases and risk-factors. They looked specifically at the well-known disparities in these areas among people of different races, ethnicities, and socio-economic status. Then--and this is the cool part--they broke the results down by age.
It's cool because it allowed them to document the difference in health maintenance among people right before and right after they reach retirement age--i.e., when they become eligible for Medicare.
The bottom line is pretty simple: Socioeconomic and race/ethnic differences in each risk-factor were much higher among working-age adults than they were in the over-65 group receiving Medicare. Mean back-white differences in systolic blood pressure drop by about half between the age 60-64 group and those aged 65-69. Differences are even more dramatic in blood glucose control. Similar results hold when one compares different educational groups.
Translation: Once people reached retirement age, they got better care for their chronic conditions. This likely had at least something to do with the fact that all of them suddenly had solid, reliable insurance through Medicare.
Like any other study, this work has limitations. The key caveat here is that retirement provides a huge cue for people to attend to their health and to see a doctor. However worthless a medical exam might otherwise be, someone will take your blood pressure and will probably prescribe a reasonable medication if your blood pressure is too high. Whatever happens in health reform, we must do a better job making sure that every American has a regular blood pressure check, and that this condition is well-treated. This is especially true in the treatment of African-Americans and others who experience high rates of cardiovascular problems. There is no just excuse for the fact that millions of people suffer strokes, disability, or premature deaths arising from such readily-treated conditions. Without discounting this challenge, McWilliams and colleagues provide good news. Covering everybody seems to reduce some of our worst health disparities. Imagine that.