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Current ambitions to expand health insurance coverage intersect with concerns to improve public health. The reform agenda in the national Affordable Care Act in 2010, and parallel legislation enacted in Oregon in 2009 and 2011, concentrates to a large degree on quality improvement in health care and delivery system reform. The idea is to make the supply of health care more efficient to reduce the cost of expanding care to a larger number of people. Public health is a corollary idea. Improving the basic level of population health can control costs by reducing the demand for health care. With healthcare expenditures taking about 18 percent of the U.S. gross domestic product, and rising, cutting costs is an understandable priority.
The cost imperative in public health emerged clearly in interviews with health policy leaders in Oregon during the development of the current reform agenda (2008–2010). Interviewees were selected by a snowball sample to represent seven stakeholder groups: state officials, insurers, physicians, hospitals, purchasers, public interest groups, and independent experts. In an hour-long interview, 37 individuals answered one question: What state-level reforms do you believe are necessary to implement a feasible model of universal health insurance in Oregon? Nearly half of the stakeholders, representing all groups, argued for a mission to improve public health.
All arguments for public health related to the sustainability of universal health insurance in an environment of overloaded demand. The most concise version of the problem came from a physician: “I think the overall health of our population is a big issue—that we are really older, sicker, and fatter.” For many stakeholders, obesity was the primary issue, regarded as a problem of epidemic proportion. All together, arguments for public health raised topics of the aging population, nutrition, lifestyle, and social factors (housing, poverty, education, and class).
A number of stakeholders, particularly from the hospital group, regarded lifestyle as the central issue in public health, and argued to somehow raise personal accountability for healthy behavior. Several stakeholders focused on careless individual behavior and the expectation of “redemption” through the healthcare system (moral hazard). Others referred to the social context of public health, and recognized the irony of supporting universal health insurance in a society where many people are homeless and unable to meet basic needs.
Increased attention to public health appears to be related to the wide dissemination of the triple-aim framework into health policy discussions. Introduced in several forums by Donald Berwick and colleagues (including a 2008 Health Affairs article, “The Triple Aim: Care, Health, and Cost”), the triple-aim focuses on three goals in healthcare reform: “improving the experience of care, improving the health of populations, and reducing per capita costs of health care.” The triple-aim intends to supersede the traditional triangle in health policy that recognizes the issues of access, cost control, and quality of care. The new framework compresses access and quality of care into the idea of the “experience of care,” and adds population health as an additional area of concern.
Several stakeholders referred to “population health,” but those that mentioned it appeared to attach two different meanings to the term: one related to public health, the other to expanded medical management. A number of arguments promoted the idea that the healthcare delivery system alone could solve many public health issues if it would expand its attention and become proactive. A model for the medical management of population health was implemented in the United Kingdom, involving new types of professional staff and funding, according to a 2003 Public Health article by Walid El Ansari and colleagues, “New Skills for a New Age: Leading the Introduction of Public Health Concepts in Healthcare Curricula.” A similar model is being developed in Oregon and other states through the federal Prevention and Public Health Fund established in the Affordable Care Act.
Contrary to this initiative, David Lawrence, in a 2010 Health Affairs article, “How to Forge a High-Tech Marriage Between Primary Care and Population Health,” argued that the optimistic view of combining population health into the model of the medical home does not represent a mere organizational expansion, but a “major departure” from the medical mission of primary care. He was skeptical it could occur or succeed, but believed innovation is possible through other business models and by empowering individuals through other venues as health consumers.
Acknowledging the distinct missions of medicine and public health is important: first, to ensure that distinct factors such as food and shelter are not neglected in the pursuit of health outcomes, and also, to separate these factors from the purview of health insurance. Combining the two perspectives fuels the ongoing trend of medicalization, which is drawing social and behavioral health problems into the domain of medical care. As several commentators have noted—including Peter Conrad, Marcia Angell, and Gary Greenberg—the clinical management of obesity, children’s moods, depression, and drug abuse are partly responsible for escalating healthcare expenditures and veritable epidemics of new types of “illness.”
Although a few stakeholders mentioned the high costs of new medical treatments, none connected the problem to the pace of innovation and expanding scope of health care. According to commentators concerned about the medicalization of public health, the trend may be encouraged by profit motives for companies involved in pharmaceutical treatments and biotechnology. Another motive appears in a research imperative, documented by David Callahan in a 2003 book, What Price Better Health? Hazards of the Research Imperative. The paradigm of progress in health care appears to be widely embraced by businesses, researchers, the state, and the public, however slight the benefits or great the cost. No stakeholder offered an idea on how to slow this march for “progress.”
Policymakers involved with healthcare reform may want to consider the independent priorities, and costs, associated with population health versus insurance for individual health risks. Reforming health insurance and the delivery system is not likely to solve the basic issues of public health, reflected in the triple-aim.
Author: Terry R. Hammond, PhD, MPH, lives in Portland, Oregon and works as an independent researcher in health policy. He has worked as a quality improvement specialist at Acumentra Health (an external quality review organization for Medicaid health plans in Oregon and Washington), and in various research positions at Oregon Health & Science University: at the Oregon Fatality Assessment and Control Evaluation program, the Oregon Evidence-based Practice Center, and with Christine K. Cassel during her tenure as dean of the OHSU School of Medicine, completing her book, Medicare Matters. This article is based on research from his dissertation, Feasible Models of Universal Health Insurance in Oregon According to Stakeholder Views. Contact Dr. Hammond at firstname.lastname@example.org.