WHERE I STAND (GUEST COLUMN):

Acute care alone can’t ensure our health

Nancy Menzel

Thursday, Aug. 6, 2009 | 2 a.m.

In August, Brian Greenspun turns over his Where I Stand column to guest writers. Today’s columnist is Nancy Menzel, a registered nurse who is president of the Nevada Public Health Association and an associate professor at the UNLV School of Nursing.

What is health anyway?

Many people (including legislators) think health is something that insurance can buy. But just as “life” insurance is really “death” insurance (it pays only when you die), “health” insurance is really “sickness” insurance (it pays only when you are ill).

But, according to the World Health Organization, health is not merely the absence of disease but also a state of complete physical, mental and social well-being. These additional dimensions help to explain why the United States, despite spending trillions of dollars annually on acute care and disease-based treatments, has shorter life expectancies than other industrialized countries and one of the worst infant mortality rates among them.

Lack of sickness care isn’t the cause of these and our other poor health outcomes. Instead, the social determinants of health (e.g., income, education, race, housing, class, employment, social support) play a much more powerful role, often through the effects of chronic stress.

That’s why there is an uneven distribution of health in the United States (and the world); the rich are healthier and the poor are sicker, the so-called wealth-health gradient. And in the United States, the gap between rich and poor is growing.

The average CEO’s salary has risen from 25 times that of his employees in 1965 to more than 250 times today. Such large income gaps have polarized Americans on whether to tax the wealthy to pay for improving the health of the disadvantaged, with the affluent fighting to hold on to or increase their assets.

Yet maintaining such inequalities worsens everyone’s physical, mental and social well-being (“health”), whether or not we are poor.

Typically, when there is a “best of” list, Nevada is at the bottom, and when there is a “worst of” list, we’re at the top. For example, we have the lowest high school graduation rate in the country, by some estimates just 47 percent. Among the many reasons for dropping out of high school, health issues (e.g., substance use, pregnancy and mental illness) are associated with failure to graduate.

These health issues then only worsen and multiply. Young people who drop out are more likely to engage in risky behavior, be arrested, be single parents, work low-wage jobs or be unemployed, develop chronic diseases, and be on public assistance.

Those with more assets then must pay for publicly funded sickness care, to hire more police to fight crime, to provide subsidized housing, and to support other social safety-net services.

Our health is threatened as well, as crime, personal resources and economic opportunities due to an inability to diversify our economy worsen. We would all have better health if we were to invest more in our educational system to promote graduation.

So, it’s time for a new paradigm. Primary prevention is always less expensive and more effective than treatment, whether for a disease or a social determinant of health. Yet in 2007 we spent 62 percent of the U.S. health care dollar on hospitals, doctors and prescription drugs to treat people, but only 3 percent on public health activities to promote population health and prevent disease.

We must equalize these percentages and recognize the profound effect our government’s educational, housing and economic policies have on health. The current debate over how to structure sickness care for all should be replaced by a debate on how to improve the social determinants of health in this country.

Discussion: 8 comments so far…

By elllvnv

8/6/09 at 8:28 a.m.

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Nancy Menzel's article was an accurate, elegant explanation of how we are missing needed health care change. I prefer a simpler metaphor, "a chain is only as strong as its weakest link" If we enable social conditions such as poor education, community breakdown (as opposed to I got mine, you dont need a thing),gatekeeper medical care rather than open discussion and preventive care, the entire chain is going to be weak. We all know that disease is opportunistic, by definition. The question is when are we going to be proactive, rather than defensive to actually win for a change?
By shrek

8/6/09 at 10:46 a.m.

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Well Said Ms. Nancy Menzel! Can we count on you to come help us march on Mr. Ensign's office in protest of his policies?
By NNurse

8/6/09 at 2:05 p.m.

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@ Shrek:

Thank you for your comment. The American Public Health Association made an appointment for me to see Sen. Ensign in April 2008 in Washington, DC to discuss children's health. His aide said he was "too busy" to meet with me personally, so I met with the aide. (Now I know why he was too busy.) When I brought up the need to fund S-CHIP programs to cover healthcare for children, the aide said that Sen. Ensign was opposed to funding expansion of such programs. She also said, in response to my question, that global warming was "not a high priority." When I asked what the Senator thought was the highest health priority facing the nation, she responded, "Gay marriage." So there you have it. Feel better now that we know what our elected leaders are crusading for?
By shrek

8/6/09 at 6:09 p.m.

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http://www.youtube.com/watch?v=vKI9be55N...

It should be jail time for health insurance executives who summarily deny client claims for profit.

http://www.youtube.com/watch?v=vKI9be55N...
By shrek

8/6/09 at 10:42 p.m.

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It's time to end our "risky experiment" of "maybe insurance". What's proven is 'maybe they'll pay', more likely they won't. It's a proven failure.

Support HR676. It's a Single Payer system that is proven, pro-business and pro-people:

* Slashes at least 30% of costs off the top by removing private insurance overhead.
* Companies take health care expenses off their books. Stock value increases. Better able to compete internationally.
* Small companies could have access to higher skilled workers because previously they couldn't compete in the labor market by offering similar benefits.
* More entrepreneurial ventures will launch since they have more money and less unrelated risk.
* Dramatic drop in bankruptcies.
* Dramatic drop in lawsuits. Most of these lawsuits are simply to obtain money to cover health care if something interrupts their coverage.
* Reduced system complexity. Greater efficiency due to fewer regulations.
* Savings from employees not having to fight with their insurers during work hours.
* HSA and MSA dollars redirected back into the economy for goods and services.
* Additional money to spend from not having to carry "uninsured motorist coverage" on your auto policy.
* Contract employment is more viable for workers since they are guaranteed access to health care.
* People are covered when unemployed. No chance of being wiped out financially if you lose your job.
* Health care providers (doctors, hospitals, therapists...) see increase in business with much less administrative expense.

*************
Read this new article in BusinessWeek (the 'maybe' insurance companies have already won!)

http://www.businessweek.com/magazine/con......

Shocking huh?
By Patrick_R_Gibbons

8/10/09 at 11:40 a.m.

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I really hate this when people think CEO pay increases are a bad thing or income disparity growth is a bad thing, or that somehow life was better "back then"

Lets see, we had racial segregation, entire sectors of the economy were closed off to women and the top marginal tax rate was 90%.

At anyrate, I think it is ironic that our public education monopoly is blamed for, at least part of, the problem. As everyone here knows, Nevada's public education system has seen its funding increased 150% since 1960 (and that is after adjusting for inflation). Clearly government management yields very poor and expensive results over time.
By Patrick_R_Gibbons

8/10/09 at 11:43 a.m.

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Also Ms. Menzel,

The average American has more than 30% the wealth of the average European. We have a far more diverse genetic pool (which does contribute to part of the lower life expectancy) we have poorer diets, we are more likely to be murdered or killed by alcohol related accidents and even then the difference between us and the Europeans is less than 3 years on average.

Research has shown that access to health insurance or universal health care does not play a statistically significant role in increasing life expectancy.
By Patrick_R_Gibbons

8/10/09 at 11:44 a.m.

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we also subsidized housing, not only has that led to housing shortages and inflation in the past it was a primary cuase of the recent housing bubble.

People, the solution to government created problems is not more government.