Last Thursday, the Supreme Court voted 5–4 to uphold the Affordable Care Act (ACA), our country’s most expansive healthcare legislation since Medicare. As intended from the outset, the ACA was designed with one prevailing purpose in mind: provide health insurance to nearly 32 million uninsured Americans, thus moving us to a nearly universal health coverage paradigm.
There are very sound moral, ethical, humanitarian, and even financial arguments in favor of universality. But the main driver for the ACA has been the notion that health insurance makes people healthier. Almost immediately following the ruling, the American Medical Association released a statement where president Dr. Jeremy Lazarus said “…we are pleased that this decision means millions of Americans can look forward to the coverage they need to get healthy and stay healthy.” But in the end, it’s hardly certain that health care for all will give us a healthier nation.
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It seems logical that when we have insurance, we are more likely to access and utilize healthcare resources, and so we will be healthier. But there’s increasing evidence showing that much of the care we receive probably provides marginal clinical benefit, and that more care isn’t always better.
Two robust studies have attempted to answer this conundrum in more depth. The first was the RAND (Research and Development) Corporation’s Health Insurance Experiment that ran from 1971 to 1982. People were randomized to varying levels of cost-sharing insurance plans ranging from free care up to 95% shared cost. The only positive correlation between health coverage and health was that free care to the poorest and sickest 6% of the sample population improved a few select problems. The nuance here is it actually improved only 4 of 30 measures that were studied (hypertension, vision, dental health, and a fourth condition called “serious symptoms” defined as chest pain when exercising, bleeding not caused by accident or injury, loss of consciousness, shortness of breath with light exercise of work, and weight loss of more than 10 pounds). So in 87% of the outcomes that were studied — such as overall physical and mental health, cholesterol levels, weight or smoking — free care made no difference.
The most recent study to tackle the question was the Oregon Health Study. In 2008, researchers compared poor people who had been randomly assigned to Medicaid or no insurance and found no mortality difference between the two groups. There was a difference between the two groups in “self-reported” health status — those on Medicaid said that they felt healthier — but it’s difficult to know, however, whether these patients were truly healthier. Even the study recognized this limitation in its results: “Given the subjective nature of the responses, it is more difficult to judge with the available data whether the results reflect improvements in actual, physical health.”
The mere act of providing health insurance probably doesn’t correlate with better health because we are actually more in control of our health, and longevity for that matter, than we realize. Good health is mostly determined by our personal choices and environments — rather than our insurances, hospitals, procedures, doctors and drugs. Even our genetics probably play only a minor to moderate role at best when it comes to developing chronic illness or cancer (with exception for strongly penetrated genetic diseases). We know this is true because of decades of research on twins that use heritability factors to quantify the genetic influence on the development of disease. With the exception of death from coronary artery disease in men, it’s non-genetic factors that hold the majority of the power when it comes to our chances of developing breast cancer, prostate cancer, colon cancer and Type II diabetes.
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Writer and speaker Dan Buettner has researched communities around the world where people live the longest and has identified nine things that he thinks make the most difference to health and longevity: 1) Move naturally. 2) Have a purpose. 3) Have a stress shedding strategy. 4) Stop eating when your stomach is 80% full. 5) Eat a plant-based diet. 6) Drink 1-2 drinks per day (preferably Sardinian Cannonau wine). 7) Belong to a faith-community. 8) Put loved ones first and 9) Hang with a tribe that has healthy attributes.
If the Affordable Care Act makes a big difference, it will be because of the preventative services provisions, which have gotten the least attention. These provisions will help all of us, patients and providers alike, prioritize higher on our agendas things like counseling on smoking cessation, losing weight, eating healthfully, treating depression, managing our relationships, and reducing excessive alcohol use. Perhaps herein lies the greatest gift of the ACA — a reminder that we still rule supreme over our bodies and our health. And that the basics — exercise, vegetables, a healthy weight, a community to belong to, a loving partner, friends that care — can take us a very long way.
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