Editor’s Note: This is the fourth in a series of posts on health and health care disparities that Health Affairs Blog is publishing in conjunction with the new March/April issue of Health Affairs on Disparities: Expanding The Focus, published with support from the Robert Wood Johnson Foundation. Brian Smedley, Richard Epstein, and Dora Hughes contributed earlier posts in the series, which will also feature Robin Weinick and Nancy Kressin.
Our technical ability to measure apparent differences in mortality, health status, and access to health care services among various subpopulations and groups continues to expand at a remarkable pace. The “identity politics” of who gets how much, compared to others, and perhaps even whether what they receive is relatively better or worse, is a growth stock within the investment portfolios of health policy researchers. The recently released fifth National Healthcare Disparities Report, produced by the Agency for Healthcare Research and Quality, provides the latest comprehensive summary of what can be measured; if not a practical guide to what we could, or should, do about it. The current (March/April 2008) issue of Health Affairs adds to the mounting literature on this topic, but it also necessarily comes up short.
Discovering health-related differences among groups, after all, remains much easier than identifying and implementing sustainable strategies for reducing, let alone eliminating, them. Why does such a “disparity” persist between the purported diagnosis and treatment of apparent health inequalities?
In many, if not all, cases, this disparity has reflected the limits of how research questions, and researchers’ curiosities, are framed. If you ask the wrong questions, the resulting answers may provide more opportunities for arm waving on the way to finger pointing than for path finding on the way to progress. When the primary measures for health disparities concern relative access to given quantities, and qualities, of health care services, they overlook the more complex total mix of possible inputs that combine to produce health outcomes. To some extent, increased emphasis on various “upstream” determinants of longer-term mortality and morbidity — such as socioeconomic status, education, neighborhood/geography, social interaction, culture, and family — can help move our disparities remedies beyond the confines of the medical services tool kit.
Yet even on this front, the temptation is to see the problem too narrowly, as one of improving the “health” rather than improving the overall “life” of any given group or larger population. After all, the benefits of growing up, and living, in environments of economic opportunity, stable family structure, safe streets, effective schools, supportive friends, and, yes, even abundant fresh fruit and vegetables extend well beyond adding another year or so of average life expectancy or delayed chronic condition onset. Recommending the obvious is preferable to ignoring it, but this raises the question of what should be done in more prioritized ways for the most disadvantaged groups and individuals with the least tractable conditions and problems.
“Just in time” interventions, even of the occasionally more efficient preventive screening nature on the medical front or the even rarer customized yet comprehensive treatment of the “whole person” on the social welfare one, still fall short of dealing with many conditions of longer latency, whose roots extend back to early childhood environments (if not initial fetal programming). As Nobel laureate James Heckman has observed in recent work, gaps in health status, like gaps in abilities and skills, show up at early ages. David Barker’s ideas on the fetal origins of adult chronic diseases (the so-called womb with a view hypothesis) suggest that to improve overall population health as well as reduce longer-standing health disparities, interventions that improve environments during early childhood — particularly for more disadvantaged and vulnerable populations — would provide more bang for the buck (at least if public policymakers were less prone to the sort of hyperbolic discounting more commonly attributed by researchers to potentially empowered health care consumers).
As a first recommendation, we need to invest more (early, if not often) in children from disadvantaged environments. At least on the public funding side, where scarce resources collide with endless cases of special pleading, this implies investing a bit less in trying to maintain the depreciated health capital of the elderly. (If you check their balance sheets, it’s all there, buried in the footnotes of the fiscal, if not political, double-entry accounting . . ..) Quite simply, interventions to boost both health and skills development are more effective in early childhood than later in life, and building mutually reinforcing early advantages for targeted populations are much less costly than trying to correct deficits and their likely consequences much later.
The tag line of the 1971 ad campaign for Fram oil filter, “Pay me now or pay me later,” can be made to work better for self-interested health care consumers with resources at risk. We need to extend their time horizons of accountability by augmenting their cognitive skills with more actionable and usable information. But for those whose early lives unfold with additional deficits and handicaps, the more realistic refrain is “Pay to help them now, or pay more later.”
As a second, complementary recommendation, it would be better to shape such early interventions more broadly, with greater emphasis on improving education quality and the development of fundamental skills, rather than delivery of enhanced health care services alone. The future health payoff — whether measured in overall health outcomes or in reduced health disparities — from better education appears to be much greater than from improved income status. Although it may in large part represent a proxy measure for expanded time horizons and the ability to defer gratification, higher levels of effective education tend to promote not just valuable human capital but also better health behaviors, greater self-control, improved treatment adherence, and more engaged patient self-management. As Angus Deaton notes, education is particularly important for women, as the primary caretakers within households.
As a third and, for now, closing consideration, the concern is sometimes raised among more single-minded advocates of health disparities elimination that improved education levels can operate as a double-edged sword, when more knowledgeable people can adopt more quickly and use more extensively new health-relevant technology to increase the gradient in health. Although this well may be the case in the short term, this misplaced concern exalts greater equality at current levels of health over higher absolute, but less equal, future levels of health across the board.
On the other hand, some value-maximizing economists might despair that no one ever offers to purchase last year’s health care technology at last year’s prices. However, the more optimistic corollary is that although next year’s more expensive health technology may at first be more available to those of higher educational, if not broader socioeconomic, status, its arrival signals that more help will be on its way (eventually) for everyone, even those more prone to experiencing health disparities.