Daniel Goldberg considers the polarizing debate about the recently published results from the Oregon Health Study on public insurance — and argues that we may be missing the point.
According to the website, the Oregon Health Study “is the first randomized controlled experiment to examine the causal effects of having some type of insurance coverage versus having no insurance at all.” The findings, released a few days ago, have unleashed a storm of commentary on what the investigators did and did not find in terms of links between coverage and health outcomes. Writing over at The Incidental Economist, Harold Pollack quotes Joseph Newhouse for the notion that the “Oregon Medicaid experiment ‘is a Rorschach test of people’s views on the ACA.’” I am going to try to defend that claim, although likely not in the way that good readers of Inequalities Blog might expect.
So here’s the funny thing: even though I am an attorney, an historian, and a bioethicist who researches health inequalities, stigma, and social justice, I actually am less of an expert on the delivery of health care services than virtually every blogger here, and likely a goodly portion of the readership, too. When interviewing for a job as a law professor some years ago, I was asked for my opinion on the fate of the ACA (then still in Congress), and I had to shrug and say that I really was not up to date on all of the provisions of the bill nor of its likely passage, nor of its potential impact. (No, I did not get the job!).
This is not because of anti-intellectualism, I believe (and hope!). This is rather because of my engagement with the overwhelming evidence that access to health care services is simply not a prime determinant of health and its distribution in human populations. In a seminal 2007 essay in Health Affairs, Paula Lantz, Richard Lichtenstein, and the good Dr. Pollack himself note that “Lack of access to health care is not the fundamental cause of health vulnerability or social disparities in health” (p. 1256).* The authors go on to warn of the limits of medicalizing health policy, and suggest that if we want to use laws and policies to improve overall population health and compress health inequities, we need to go way beyond simply expanding access to basic health care services.
I think this is an important point, and it is one I teach, speak, and write on in a variety of ways. In fact, it is in some way a point of departure for virtually all of my work in public health ethics and public health law. We have strong evidence, both historically and over the last half century, that access to health care services is only a relatively minor determinant of health and its distribution in human populations. This evidence begins with the McKeown Thesis (in which the single largest recorded gain in life expectancy in Western history had little to do with organized medicine) and goes on through the Whitehall Studies (in which all subjects had access to basic health care services and stark social gradients in health were observed) and more than a few others. I discuss some of the implications of this evidence here.
Ok, there is some debate on this subject; some argue that mortality declines in the past half-century are mostly attributable to medical innovation delivered through health care services. I am dubious of these claims for a variety of methodological reasons (First, I think the studies tend to lump together public health interventions with clinical medical services. Given that majority opinion on the McKeown Thesis notes that much of the mortality gain during the health transition is attributable to organized public health activity, we have every reason to believe such a lumping is unjustified. Second, I think such studies do not, perhaps cannot, adequately control for the intergenerational effects of social and economic conditions over the life course).
But I am comfortable suggesting that the general consensus is that upstream social and economic conditions are by a fair margin more significant determinants of health and its distribution than access to medical services.
So, where does this leave us with regard to the Oregon Health Study? I have no idea, actually. I am no expert on the bowels of Medicaid, and as I live and work in an extremely underserved region with devastating health inequities, far be it from me to claim that access to Medicaid in insignificant. In fact, as I argue at length, we need to be very careful in the implications we draw from the above evidence. First, it does not imply the moral insignificance of expanding access to health care services. No matter how we structure society, people will fall sick, and I have no hesitation in saying that we ought to care for them. But we should not confuse this ethical proposition with an empirical counterfactual, viz., that in a world in which we did expand such access we would see significant improvements in overall population health. Second, beware the false choice fallacy. There is no contradiction between collective action on the SDOH and expanding access to basic health care services.
Does the Oregon Health Study support my claim above? Again, I have no idea. And really, it is besides the point I am making here. Even if it is the case that some kinds of access to health care has a positive impact on health outcomes — a conclusion I would of course never deny globally or even in any specific case – the weight of the evidence strongly suggests that if we wish to have a substantial impact in overall population health and in the compression of health inequalities, we will have to take collective and social action far, far beyond the provision of health care services.
The Oregon Health Study: definitely a Rorschach test.
* The choice of language of “fundamental cause” is important inasmuch as it invokes Link and Phelan’s fundamental cause theory of disease. More on this in another post.