After the ACA: addressing health before health care

By Daniel Weintraub

Supporters of the Affordable Care Act say the controversial law is the country’s best hope for improving the health of all Americans and slowing the growth in health care costs. Opponents say it will do the opposite: driving up the cost of care, disrupting relationships with our doctors, and making Americans more dependent on their government.

But what neither side acknowledges is that even if the law works exactly as intended, it is unlikely to have much effect on how healthy we are, how sick we get and how long we live.

The Affordable Care Act, at bottom, is more about health insurance than health care. And even the parts about health care are not necessarily about health.

That’s because while nearly everyone would like to have access to health care at a reasonable cost, it has become increasingly clear that our health is shaped by forces far greater than our ability to see a doctor or afford a stay in the hospital.

Wealth and poverty, education levels, the environment and stress play a greater role in how long we live than does the medical industry, for all the billions of dollars we spend on it.

Your zip code, in fact, tells you more about your life expectancy than your health insurance status.

In Orange County, a baby born today in the poorest part of Santa Ana can expect to live 78 years, on average. A baby born the same day a few miles away in Newport Beach is likely to live a decade longer, 88 years.

Would giving everyone equal access to health care change those numbers? Probably not much.

A study released earlier this year in Canada provides a clue. That research found that control of type I diabetes in children was correlated with the income of those children’s families – despite access to free health care for all. Controlling the disease requires multiple daily blood tests and insulin injections, and researchers concluded that children in wealthier families were more likely to have the support they needed to keep up with their care.

That’s just one example, involving one disease. But the same trends can be found over and over.

According to rankings of every county in America by a project of the University of Wisconsin, Orange County is the seventh healthiest in California. Nearby San Bernardino is the 44th healthiest among the state’s 58 counties.

Residents of San Bernardino are more likely to report having only poor or fair health, more likely to be obese, more likely to have had a preventable stay in the hospital and more likely to die prematurely, before age 75.

And it is probably no coincidence that residents of Orange County are less likely to live in poverty, more likely to have a high school or college education, have less unemployment, less violent crime, cleaner air, more recreational facilities, better access to healthy foods and less access to fast food restaurants.

Chet Hewitt, president of the Sierra Health Foundation in Northern California and a big supporter of the Affordable Care Act, says people are going to be disappointed if they expect the federal health reform to make the population significantly healthier. While it will be helpful, he says, the law is directed more at what he calls the “sick-care” system – the doctors, hospitals and drugs that we need once something has already gone wrong.

“When you think about fixing the sick-care system you are not thinking about health and well-being,” Hewitt said. “If the assumption is that expanding health insurance is going to fix that, I’d call that a lack of informed insight.”

There is one part of the Affordable Care Act that is aimed directly at trying to change the underlying conditions that affect our health. The law sets aside money for “community transformation grants” to local governments and non-profit organizations to encourage tobacco-free lifestyles, active living and health eating, and preventive services aimed at heart disease, diabetes, high blood pressure and other chronic conditions.

The money will go toward making neighborhoods more friendly to pedestrians and bicyclists, improving and expanding parks, protecting safe routes to schools, expanding access to healthy foods and improving preventive care, including the management of chronic disease.

San Diego County has been an aggressive early-adopter of these ideas, and leaders there refer to a threat they call “3-4-50.” Three behaviors (poor diet, lack of physical activity and smoking) contribute to four chronic diseases (heart disease/stroke, cancer, Type II diabetes and lung disease) that cause more than 50 percent of the deaths in the region. County residents and the government spend more than $4 billion a year treating these four diseases alone.

In part because of the county’s efforts, heart disease and stroke have moved from the leading cause of death from chronic disease to the second leading cause, and the county was recently found to have the largest reduction in child obesity in Southern California. And a pilot program at a local hospital dramatically reduced the rate of re-admissions for chronic disease patients by giving them intensive instruction in how to care for themselves upon leaving the hospital.

A lot of this might sound simply like common sense, and it is. But the importance of such simple ideas and solutions have been lost amid the controversy over the Affordable Care Act and the fight over how to expand access to insurance, doctors and hospitals.

Maybe, once the dust begins to settle on that fight, we can get back to the more important question: what can we do to improve the health of all Americans?

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

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