universal coverage vs public health

Universal medical coverage and comprehensive public health are not at odds. Each should further the goals of the other. But in thinking about policy that moves our society towards a more healthy citizenry looking at each of these goals as separate and even contrasting them may be helpful in getting direction. The tendency of the liberal left is to focus on universal coverage. I would concur that the value of society caring for all of its members is paramount. But the failure to provide comprehensive and unbiased public health education and interventions may have a greater impact on people’s health than universal access to primary, tertiary and pharmaceutical care. This post is meant as an exploration of this question, not an answer.

Public health includes many foci: Education for self care which includes information on lifestyle choices that promote decreased morbidity and increased longevity, and information on the prevention of the spread of infectious diseases. Interventions to promote a healthy environment, this includes promotion of sanitation, creation of healthy options and actions to address toxic hazards. Management of communicable infectious diseases, this can involve health screening, immunization and treatment.

Universal coverage generally includes expansion of medical coverage to everyone. While at the present virtually anyone can legally walk into an ER and be treated, this is very limited care, and even this many people avoid for fear of the bill or quality of care. Primary care is regular access to a clinician or clinic where a medical overview can be kept, sometimes called a medical home, or your regular doctor. Tertiary care includes advanced hospital care and medical procedures. Finally many don’t have access to needed pharmaceuticals. These are the major challenges of universal coverage.

Early public health problems included problems of sanitation and control of infectious disease. The role of sanitation probably has more to do with improved health statistics than any amount of medical care. World wide this is still a major problem. In the US it has generally been addressed with exceptions largely related to poverty, aging infrastructure and privatization of water systems. Successful elimination of small pox is perhaps the greatest single disease focused public health success stories. We are now only a few hundred cases away from the eradication of Polio from the planet in the same way. With greater acknowledgment of the problem and public health efforts to contain it, the HIV virus might have never spread as broadly as it has.

The major health problems facing the US today are largely chronic diseases. These diseases are rooted in problems of the dominant contemporary lifestyle. This lifestyle includes lack of physical activity, excessive and inadequate nutrition, high levels of psychological stress, and exposure to environmental poisons. Physical exercise is naturally reduced by convenience devices, not the least of which is the personal automobile, but there are ways of promoting exercise that don’t involve eliminating the car. Much could be said about the nutritious roots of chronic disease. Beyond admonishments to eat your vegetables, Americans suffer from a excess of unhealthy fats and sugar, and inadequate amounts of many essential nutrients. Most people don’t realize that the stress in their lives has costs beyond its psychological impact. Stress contributes to the metabolism that leads to obesity and the many chronic diseases that are related to it. Finally we don’t know nor can we adequately measure the effects of the thousands of new chemicals that are released into our environment every year.

Lets look at the central chronic disease complex that faces adult Americas today. At the pinnacle is heart disease, cardiovascular disease is the number one cause of death in America. But Obesity and Diabetes rates are on the rise. 1/3 of Americans meet the criteria of Obesity and it is estimated on current trends that 1/3 of children born today will have diabetes in their lifetime. In 2005 the New Engalnd journal of medicine published an article indicating that although the life span for humans had consistently increased for 200 years, we are now facing a likely decrease in life expectancy. The rational for this conclusion was the rise in obesity and diabetes. Diabetes contributes to the risk of heart disease, obesity contributes to the risk of diabetes and heart disease. Together risk markers for these three medical conditions make up what is called metabolic syndrome. The likely contributing factors for metabolic syndrome include: Consumption of a diet rich in simple sugars, or what is often called glycemic load. Trans fats, artificially hardened oils that are not found in nature. Excess and unhealthy dietary fat, and unbalanced ratios of healthy fats such as the omega 3 fatty acids. Not eating enough vegetables, or a lack of adequate and diverse phytonutriants. Insufficient cardiovascular exercise. Lack of strength building exercises. Smoking and consumption of other drugs that have significant cardiovascular effects. Exposure to environmental toxins including heavy metals and zenobiotic. Stress also plays a role in the development of Metabolic syndrome.

Clinical interventions regarding these risk factors might include some brief education, a hand out, and occasional referral to further educational or behavioral change programs. In reality even the briefest education is skipped over in most clinical visits. Public health interventions could address any of these contributing factors in a wide variety of ways. I will give several example of potential public health interventions that could improve Americas nutritional habits as they relate to metabolic syndrome. This is not intended as a proposal or an endorsement, but as evidence of the power of public health interventions. Any public health intervention merits careful consideration regarding its full effects, its costs, risks and adverse consequences as well as its potential benefits.. Nonetheless many of the examples I give have been used to reduce tobacco smoking. And some are being tried regarding food.

Public education regarding healthy nutrition, such as a national add campaign, limitations on the advertising of unhealthy foods fast food chains restricted from advertising on television, or require labeling of foods with information about their health risks or benefits, food labels do have quite a bit of information but for instance information about glycemic index and glycemic load could be helpful in identifying healthier carbohydrates. Taxing or preventing the sale of food substances or additives, new york city for instance has moved to stop the sale of trans fats within the city, mandating a variety of food options in a given area, one city in California has placed limits on the number of fast food places that can operate in a specific community. Promote research to further develop our understanding the role of improper nutrition in the development of metabolic syndrome. Cut subsides to corn which is a subsidy to high fructose corn syrup and to the cattle industry. Instead, subsidies the growth of garden vegetables. If the USDA is correct that a significant number of Americans diets are deficient of several essentials nutrients including vitamins A, C and B complex, calcium, magnesium, iron, and zinc to name a few, providing discounted or even free multi vitamins might have major heath benefits. Establish national broccoli day. The possible public health actions one might imagine are unlimited.

Public health interventions are of course limited by corporate political pressure. For instance, a recent major study published in the Archives of Internal Medicine found that red meat consumption associated with increased mortality. It is unlikely that that the cattle industry will let this information work its way into America’s public health policy

Nonetheless, my premise is that public health measures are better for providing preventive medical care, universal coverage provides improved quality of disease management and care. When thinking about individuals and their health and suffering I think that prevention may be more important than disease management.

Let me offer two scenarios: In the first case there is universal coverage, everyone gets insurance as good as those in congress have, but chronic disease rates continue to clime. The second scenario involves public health measures that result in substantial reduction in chronic disease rates but coverage continues at it’s present levels. Lets look at these scenarios in terms of mortality and morbidity, morbidity being a measure of ongoing physical disability and suffering. Scenario one might result in a shorter life expectancy for many, perhaps some who had not been insured but had become insured might live longer than they would have. But if the JAMA article is correct chronic disease would likely overwhelm those gains. In scenario two we might see people on the whole living longer although those with out insurance would not get care that might help them to live longer in certain circumstances. Disability and suffering is much the same. Chronic disease brings with it morbidity, health care can mitigate but not eliminate morbidity. Public health can not make all disease go away and those with out full access to medical care suffer more. One might think of it as a trade off suffering of those who don’t have insurance or suffering of those who will get a preventable chronic illness. I think it is possible that life expectancy would be longer and more suffering would be eliminated by instituting reasonable measures to reduce preventable chronic diseases than by providing universal access.

From a strictly utilitarian standpoint public health may win out. But principal of fairness and equality also need to be considered. At first glance it may be the working poor who suffer most if coverage is not extended to all, but the burden of chronic disease is not spread evenly, it too has a class bias against the poor. One might think that this is just due to coverage but we see the same pattern in countries with universal health coverage.

There are serious issues related to the government taking a heavy hand in directing lifestyle choices, particularly when the government so often represents corporate interests.

Finally cost is a complex issue beyond the realm of this post.

This post is speculative, I don’t have the facts or numbers to back up a case for greater public health over universal coverage, and I hope it isn’t a choice one or the other.