Off the chart
Thursday, January 22 2009
After linking to Ezra’s link to the Health Affairs article on social determinants of health, Matt Yglesias throws up this chart (originally from a NEJM article by Steven Schroeder, MD):
Matt argues the chart shows that “health care” is a rather small part of “health outcomes”, which he claims is a point often lost in the debate over health care reform.
Yes and no – but mostly no. Yes, social factors play a big role in health outcomes; read the article from Health Affairs.
But no – health is not the absence of premature death. A person can live a long, long time yet sick as crap in our health care system; according to this chart, that counts as “health” so long as the person doesn’t die prematurely.
And no – nobody has a genetic predisposition to “premature death”. People do have genetic predispositions to illnesses, which can then lead to premature death. For example, I have a genetic predisposition to Crohn’s disease; said disease might lead to my untimely demise, in which case it could be considered a death due to genetic predisposition. What Matt implies is that “health care” is then irrelevant to my “health”, because I was doomed by bad genes. That’s a pretty screwed up way of looking at things – a little insulting, even.
If I don’t die prematurely, then my life (and death) doesn’t even show up on the chart. By Matt’s implication, I don’t count because I somehow managed to eke out a normal life span – but the only way that will happen is through intense, sustained use of the health care system. And for me, the stakes in the debate over health care reform are the nature and quality of my life as a sick person in that system – not the timing of my death.
Yes – preventing premature death is an important goal of a health care system. But just as important – maybe even more – are the lives of people while they’re still alive.
Update: Now Ezra has the chart, which he uses to suggest the health care debate is too bogged down in “health spending”, and not enough in how we can make people healthy:
Part of the reason our health care is so expensive is that we tend to think health is the sort of thing that happens inside a doctor’s office. But it’s not. [...] What happens in the hospital is not health care, it’s disease response. It’s what happens when something has gone wrong in the other spheres of your life that make up your health. And the cheapest health reform of all would be the one that keeps us out of the health care system entirely.
Actually, heath care is the sort of thing that happen’s in a doctor’s office – along with a lot of other things. Disease response is part of health care (why is that not obvious?). What happens when something goes wrong is part of health care. Yes, we can reform health care so that these aspects play less of a role and cost less (in favor of more proactive measures), but that’s little help for the people who need disease response right now – which is millions of Americans, last I checked.
