What we really need is health reform, not just health insurance reform.

 Interesting, exciting, confusing, frustrating, and disappointing are just few of the more generous terms I can use to describe the current state of what is being called the “health reform” debate in the U.S. 

 I pose a few basic questions and respond based on what the likely outcome appears to be: an private insurance-based system with no “public option”.

 Is it really “health reform”? 

Hardly.  Let’s call it “health insurance reform.” It’s about removing one major barrier for those without health insurance: money. However, providers of care – hospitals, physicians, and others- do not have to accept whatever payment system will be in place. So access may still be limited. For example, in the Ithaca area where I live only about half the physicians are currently accepting new Medicare and Medicaid patients. Will they accept new patients in the future?

 Health insurance reform will not likely diminish the inequalities that exist due to factors such as race, gender, sexual preference, geography, education, and social status.

 What would “health” reform look like? 

There are two ways to answer this. 

First, we would have to change the mechanism and culture of medical care.  A “health” system that focuses on keeping people healthy instead of rewarding the treatment of the ill would prevent problems and likely save an enormous amount of money over the long run. Initial investments in changing our system will be costly, but will be worth it.

For example, we pay cardiologists in the thousand of dollars for performing 60 minute procedures in their offices or outpatient clinics. However, we pay them much much less for spending 60 minutes with their patients discussing ways to improve or maintain their health status such a nutrition, stress reduction, and physical activity. What do you think most doctors decide to do?

 Second, let us consider the areas know as the social determinants of health. 

We know that “health” is far more than access to medical treatment.  Consider the “choices” one has for purchasing healthy food on a low fixed income, for example.  What food stores are available in their neighborhood? What parks or recreation opportunities are available? Is their neighborhood safe?  Therefore, “health” reform means doing something to increase and improve the choices one has where they live.

Here are other social determinants of health:

race, education, housing, employment and occupation, and stress.  We rarely consider these when discussing “health insurance reform.”  

So we need to change the terms of the debate.

If the goal of reform is to improve health status for as many people as possible, then removing financial barriers to care is only one way. Investing in better housing, wider access to education (not just health education), healthier neighborhoods, food policies with consumer health as a priority, healthier workplaces, and acknowledgement of racial inequalities in health would mean real health reform.

Here are a few sources to check out:

Reaching for a Healthier Life: Facts on Socioeconomic Status and Health in the U.S. (This is a clear and concise explanation of the social determinants of health.)

www.macses.ucsf.edu/.../Reaching%20for%20a%20Healthier%20Life.pdf

Unnatural Causes: Is Inequality Making Us Sick?

I don’t need to know if you are sick. Or do I? How about if you have a contagious illness? Perhaps H1N1? 

Fortunately, the latest pandemic has not been as fatal as we had feared. While tragedy has struck some families, the death rate is about the same as or less than seasonal flu. Most of those who have perished had prior illnesses or conditions that left them susceptible to opportunistic infections like H1N1.

In the Ithaca community, tragedy struck a Cornell senior who became the third college student to die from H1N1 in the US.  We do not know if any prior conditions contributed to his death. Yet, headlines in the Cornell Daily Sun this week read:

Hospital Says It Has Not Discussed Whether Any Underlying Condition Contributed to H1N1 Death

The laws are clear: patient privacy is secure and protected. Only the patient or the family has the right to grant access to health information.  Even when the climate of fear permeates the community, our culture and laws value and protect the individual right to privacy. For that we should be thankful. For now.

What about the next epidemic? When the extent of the disease is more widespread, the fatality rates are higher, and underlying conditions are an obvious risk factor? What can we learn from the current epidemic? Shall we do anything different? Dare say, shall we suspend the laws and culture of privacy, for example? They do that in many other parts of the world in order to protect the public's health.

Do I need to know if you are sick? Or did you have an underlying condition, or not? Is the greater responsibility to protect the community or the individual right to privacy?

Stay tuned. The next epidemic is…..

Meanwhile, here is my highly recommended reading for this subject: The Last Town on Earth by Thomas Mullen; a novel about the morality issues of isolation, quarantine, and fear surrounding the deadly 1918 flu pandemic.

Public health spaces are everywhere.

Public health is about prevention through collective action involving teams of health professionals from engineers, to basic scientists, policy makers, health providers, and dozens of others.

Medical Care is about treatment and cure primarily revolving around the physicians’ treatment of individuals. About 95% of resources in the US go toward medical care.

So as public health advocate, medical care is “strange” to me as in the metaphorical sense that Heinlein presented in his famous novel. This blog will attempt to articulate my public health position as a counterpoint to the dominance of medical care.

In other words, I am a public health stranger spying on the spaces occupied and colonized by medical care.