America’s Poor Health Outcomes are Driven by Behaviors – Not Coverage or Access to Care

And that’s a much harder problem to solve than expanding health coverage.

In recent weeks, health policy wonks have been salivating over a new book by two of the country’s most respected economists, Amy Finkelstein and Liran Einav. The central proposal in their book, “We've Got You Covered,” is that the U.S. should implement a universal, publicly funded system of basic health insurance, with a robust market for supplemental private coverage.

It’s tempting to think that Finkelstein and Einav’s plan is designed to reverse the worrying trends in a range of health outcomes that have been documented over the last decade. After all, their book’s release coincides with a deepening mental health crisis, rising obesity rates and declining life expectancy.

Yet the authors write: “There are good reasons to support universal health coverage, but noticeably improving population health is not one of them. … Indeed, the evidence suggests that the health disparities among Americans are not driven by differences in access to health insurance or to medical care. Rather, the key to improving health is far more complex: It lies in changing health behaviors and reducing exposure to external sources of poor health.”

Finkelstein and Einav are spot on, though their statements are unlikely to sway the health policy establishment, which regards the insurance rate as the ultimate gauge of the nation’s health.

As I argued in a previous post, health insurance and health outcomes are strongly correlated, but the case for causation is weak – their tight association largely stems from the fact that people who have health insurance tend to be healthier (for other reasons, like having a stable job, safe housing and a good education). Indeed, the evidence suggests that lack of access to medical care accounts for only about 10% of premature death or other negative health outcomes. The genes we inherit – and the diseases they predispose us to – play a much larger role: 20-30%, by some estimates.

But no single factor has more influence over health outcomes than personal lifestyle habits, especially substance use, overeating and physical activity. And it is in this category that the U.S. falls far short of its peer nations. The three-fold increase in obesity the U.S. has experienced over the last 60 years, for example, is virtually unique. In the early 1960s, severe obesity (BMI > 40) was virtually non-existent. Today, the condition affects 1 in 9 American adults.

As NYTimes columnist Nicholas Kristof recently put it trenchantly, “Americans are among the least healthy people in the rich world, and among the most likely to die early.”

In some parts of West Virginia, life expectancy at birth is just 57 years – roughly where the U.S. average stood in the 1920s, before the discovery of basic medicines like penicillin. At 55 years, life expectancy in South Sudan (GDP per capita: $1,000), a nation wracked by famine and civil war, isn’t far behind. It’s not that West Virginians don’t have access to medical care – if anything, they consume more healthcare services than the national average. The real challenge is that West Virginia has some of the highest rates in the nation of drug use, smoking and poor dietary habits.

Nationwide, these preventable factors drive up to half of all premature deaths. If the U.S. is to curb its health care spending and reverse course on myriad health indicators, tackling the thorny issue of health behaviors is unavoidable.

But encouraging healthier lifestyle choices at the population level is no easy task. Our understanding of the forces behind the precipitous decline in smoking, from 42% in 1965 to about 14% today, for example, remains limited. Public policies including anti-smoking campaigns, restrictions on smoking in public and tobacco taxes have surely played a role, but the main cause seems to have been a cultural shift away from seeing smoking as cool or normal. Can we replicate a similar shift with respect to overeating or abusing drugs? Let’s hope so.