Health is about more than health care

By Daniel Weintraub

Barack Obama’s re-election appears to have settled the future of the Affordable Care Act, the president’s health reform law. The law will evolve in the years ahead, perhaps in ways that no one now anticipates, but it will not likely be repealed any time soon.

As a result, several million Californians who do not now have insurance coverage will get it, either through the government directly or by buying it with subsidies at a new online marketplace to be known as the California Health Benefit Exchange.

But for all the hype and controversy over the Affordable Care Act, the law is really more about insurance than health. Insurance coverage is a good thing. But by itself it is not likely to make Californians much healthier.

Chronic disease, which can often be prevented and can almost always be managed, accounts for 75 percent of all deaths in California and a similar percentage of health care costs.

And here is the most striking fact: the worst of these diseases – obesity, diabetes, and heart disease – are all correlated with geography, and by extension, with income. Where you live tells us much about how healthy you will be and, ultimately, how long you will live.

In 2010 a Bay Area group looked at life expectancies in that region and found that people living in West Oakland, on average, lived 10 years less than those who lived in the Berkeley Hills. Across the bay, residents of Hunters Point in San Francisco could expect to live 14 years less than those who lived on Russian Hill, a few miles away. Similar disparities can be found all over the state.

Consider Marin and Lake counties in Northern California, just a few miles apart on either side of the Wine Country.

Marin is annually named the healthiest county in California in a national report compiled by researchers at the University of Wisconsin. Lake County is one of the least healthy in the yearly survey.

In Marin, compared to Lake County, babies are born healthier, people live longer, and residents report being sick relatively rarely.

Interestingly, in both counties roughly the same share of the population, about 17 percent, is without insurance coverage.

But there are important differences.

The people of Lake County are more likely to smoke, be obese and have children while they are still teen-agers. And all of these behaviors have been shown to lead to less healthy outcomes in the long term.

It might be easy to attribute these things to bad choices, bad parenting, or a lack of personal responsibility.

But increasingly, research is suggesting that there is more to it than that. People do make choices, but not in a vacuum. The healthy choice is not always the easy choice. And for some, their environment and living conditions may be programming them from childhood to be destined for disease.

In Lake County, far more kids live in poverty than in Marin. Families are more likely to be headed by a single parent. More students drop out of school. And residents are more likely to be a victim of violent crime.

Research, some of it old, some of it new, tells us that all of these things can affect our health.

A Kaiser Permanente study of 17,000 San Diego patients in the 1990s, for example, found that childhood trauma led to increased levels of chronic disease later in life.

Dr. Vincent Felitti, working with researchers from the Centers for Disease Control, administered a 17-question survey to 17,000 patients, asking them about their upbringing. He asked them whether their parents were divorced, if they had witnessed domestic violence, and if they had been physically, sexually or emotionally abused.

He found that the more trauma these patients had experienced as children, the sicker they tended to be as adults. They were more likely to smoke and drink and overeat, more likely to die young, suffer heart and lung problems and develop cancer.

More recently, researchers at Duke University and King’s College in London found that the DNA of children who have experienced violence shows signs of the kind of weathering typically associated with aging, leaving them more vulnerable to disease.

And research from Carnegie Mellon University recently used the common cold as a model for exploring the link between stress and illness.

The team recruited 276 volunteers and interviewed them to determine their levels of stress. They then exposed the subjects to a cold virus and quarantined them for five days.

The results: the subjects with the most chronic stress were the most likely to develop full-blown cold symptoms.

Why? Because their immune systems were compromised, and they were unable to regulate inflammation normally. The researchers concluded that overexposure to the hormone cortisol, which our bodies produce when under stress, eventually causes the immune system to stop responding the way it should.

And the same compromised immune systems that leave people vulnerable to the common cold can also make them more likely to fall ill with other, far more serious diseases.

All of this research and more suggests that simply giving people access to insurance and even to doctors, while laudable, is not going to do much to change health outcomes in the US, including California.

If we want real change, we need to change the way we live in ways big and small.

And there are some encouraging signs.

The Affordable Care Act did include $15 billion over 10 years for new preventive programs, including grants intended to transform communities to make them healthier places to live.

In California, former Gov. Arnold Schwarzenegger created the Health in All Policies task force to look beyond the narrow agenda of each state agency and examine policies that cut across government. Much of its work, which has continued under Gov. Jerry Brown, is looking at land use policy and the rules that shape our urban environments.

Policies that would make walking and bicycling not only possible but also attractive alternatives to the automobile would likely improve our health as well.

They would increase physical activity, which can decrease heart disease, stroke, depression and obesity.

They would improve air quality, which can reduce respiratory and cardiovascular disease.

And they could decrease greenhouse gas emissions.

Local governments, community based organizations, and other institutions are also working on making our neighborhoods healthier in many ways.

Police are working with community groups in the violence-prone city of Richmond to reach out to at-risk kids and help them stay out of gangs.

In Alameda County, a federal grant is giving low-income residents access to banking and credit so they can reduce the stress that comes with unmanageable debt.

In Sacramento, UC Davis doctors are working with landlords to improve the living conditions of tenants who are frequent visitors to clinics and emergency rooms because of illness caused by their home environment.

Not all of the progress we need will come this easily, or this cheaply.

But it’s safe to say that while the expanded coverage provided by the Affordable Care Act might be a good start, the change we need is more likely to be found in our homes, our schools and our neighborhoods than in our clinics and hospitals — or in the fine print of a new insurance policy.

Daniel Weintraub has covered California public policy for 25 years. He is editor of the California Health Report at

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