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No one who is concerned with justice as a basic principle would deny the value of income redistribution, particularly in view of the powerful relationship between income inequality and ill health. The policy question turns on issues of feasibility, practicality, and time frame. What might be complementary strategies while the struggle for income redistribution takes place?
Few realize that the health of the US population is worse than than the the populations of many other industrialized nations.
Most people know that the United States has the most costly health system in the world, but few realize that the health of the US population is worse than than the the populations of many other industrialized nations. The only major health indicator for which the United States is not near the bottom of the rankings is life expectancy at age 80 or older. In the general scheme of things, there are many determinants of ill health (biological, social, psychological, environmental, genetic) and they are likely to act in ways that differ in different population subgroups. While more doctors, more hospitals, and more technology rarely, if ever, produce better health of populations, certain aspects of health systems do have a positive impact on health. That is, relatively new health policy studies show that health systems that are better oriented to primary care, with specialty care serving primary care rather than the other way around, achieve better health. As a strategy for achieving equity in health services delivery primary care is generally associated with other progressive political approaches, such as more equitable tax policies and better distribution of income. But even then, studies have shown that areas that are better endowed with primary care physicians and less well endowed with specialists have better health as measured by a wide variety of health indicators, regardless of the degree of income inequality. This is the case both internationally and within all fifty US states. Still, the strength of the relationship between primary care resources and health varies across different population subgroups, indicating that other determinants also play an important role.
Most people in the United States think that having free access to specialists assures them the best quality of care, thus reflecting an unmitigated faith in the power of medical and surgical tests and procedures. Although access to specialists is important for those who need it, unrestrained access to specialists is potentially dangerous. Unnecessary technology, which is more often applied by specialists than by primary care physicians, can be harmful to health. So are many medications. Estimates of the unanticipated adverse effects of technology and medications, along with the adverse effects due to errors in their administration, account for somewhere between the third and fourth leading cause of death in the United States.
A long-term relationship with a primary care practitioner can help people decide when specialty care is not really needed, thus reducing the ill effects of non-indicated interventions. Public realization that the goal to improve primary care, including appropriate referral to specialists when indicated, is critical to improving the health of the population. It is no accident that the elderly have the best health status (relative to other countries): they are the only segment of the population with continuous assured financial access to health services since 1965, which made it possible to build long-term relationships with primary care physicians.
In its focus on profit-making and cost-cutting, managed care, in its current incarnation, fails to fulfill any of the important functions of good primary care.
Income redistribution may go a long way to improving health, but there will also have to be simultaneous attention to changing other social and health policies. As one pundit said, "For every complex problem, there is a simple solution, and it is wrong." There is no simple solution to reducing systematic health inequalities. A policy reorientation that recognizes the importance of universal access to high quality primary care services backed up, when indicated, by appropriate specialty care resources, is a critical part of the strategy. Managed care has derailed a national focus on building a strong primary care infrastructure by pretending to be organized around primary care. In its focus on profit-making and cost-cutting, managed care, in its current incarnation, fails to fulfill any of the important functions of good primary care.
Unfortunately, a poorly informed public focuses on the ills of managed care without understanding how managed care got here in the first place. People want direct access to specialists, in the mistaken belief that this will improve their health, without any recognition that they risk harm to health from over-use of potentially dangerous interventions. The evidence is clear that the best way to achieve better health is to greatly enhance the contributions of primary care, which focuses on meeting and solving people’s health needs, including appropriate referrals when they are indicated. A more informed public and better public policy will have to be marshaled to address the many possible approaches to reducing the systematic disparities in health across population subgroups and the relatively dismal health status of this nation. Income redistribution is important, but it is unlikely to happen any time soon. In the meantime, other strategies, including improving the equity-enhancing aspects of health systems, are likely to be more practical and feasible.
Barbara Starfield, Professor of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health, is author of Primary Care: Balancing Health Needs, Services, and Technology.
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