There’s more to good health than health care


By Trudy Lieberman

 Rural Health News Service

Because so much of the national discussion lately has centered on health, the Affordable Care Act and its troubles, you might think that health insurance is all that matters when it comes to making people healthy. It isn’t. That good health is more than health care was a point I heard many times on my recent Fulbright fellowship visit to Canada, and it’s a topic we don’t talk much about in the U.S.

I visited a doctor in Toronto who has created a simple brochure — he calls it a poverty tool — to help doctors think about poverty during office visits and help their patients cope. For example, the tool tells docs to factor poverty into an assessment of a patient’s risk factors, say for diabetes.

The Canadian Medical Association held town hall meetings this year in several cities, and participants identified nutrition and food security, income, housing, and early childhood development as the main drivers of good health.

A major Canadian study has found that providing private apartments for homeless people who are mentally ill has made a difference in the quality of their lives and social functioning. Plus they are using more health services in their communities rather than in more expensive hospitals. Redirecting services to less expensive community facilities is a goal in Canada as well as in the U.S.

Wherever I went, I heard a lot about what the nation can do to improve the health of what Canadians call their aboriginal populations. The health problems — diabetes, mental illness and obesity — that plague Canada’s native populations are the same ones Native Americans face. But I don’t hear many people in U.S. health care circles talk much about our native populations.

And I heard more talk about what can be done to improve the health of Canadians in general than I heard complaints about their infamous waiting lists for cataract or hip replacement surgery. Dr. Marcia Anderson DeCoteau, a physician on the faculty at the University of Manitoba, told me that education contributes to every health outcome from kindergarten on, and if people are poorly educated, that deprives them of good health from the beginning. “The impact to the country of reducing wait times to improve population health is minimal,” she said.

Throwing more money into medical services and using more of the “newest” medical services and “greatest” technology doesn’t always bring better health as we can see from the latest international survey from The Commonwealth Fund, a New York City philanthropic organization focused on health care. (Full disclosure. The foundation funds Thinking About Health columns.)

For more than 10 years, the Fund has surveyed patients in 11 countries about cost, access and quality, and each year, contrary to our widespread belief that we have the best health system in the world, the U.S. comes up short. For starters, the U.S. spends more per person on medical care than any other country. This year spending hit $8,508 per person compared to $5,669 in Norway, the next highest spender. When it came to spending on administrative costs for insurance, the U.S. led the way spending $606 per person compared to France and Switzerland, which spent $277 and $266.

About one-third of Americans spend a lot of time dealing with insurance paper work and fighting with their carriers over claims. In countries like Germany, the Netherlands and Switzerland, which have competitive insurance markets, far fewer citizens spend less time on insurance hassles. For instance, only 17 percent of Germans complain about insurance matters. Both Americans and Canadians report longer waits for primary care when they are sick.

Given those stats, it’s hardly surprising that 75 percent of Americans said the system needs fundamental changes or should be rebuilt. If and when the Affordable Care Act is successfully implemented, some of these problems are likely to get worse because the system still will not have fundamentally changed, and some patients will shoulder higher out-of-pocket costs.

As patients, consumers of health care, or just ordinary Americans, we need to think about our health care system more broadly and ask what are we getting for all the money we spend. And if we decide to keep the title of the world’s biggest health care spender, exactly what are we getting for all that money?