Beyond Doctoring

I’ve long been amazed by the legerdemain that went into deciding what Medicare will cover and what it won’t. I’m not talking about decisions made in the past decade about what procedures to pay for, by and large rational decisions that have been based on a careful analysis of the evidence supporting their efficacy. I’m talking about some of the most basic aspects of Medicare, such as its exclusion of long term care. Now I recognize that the main concern of those who crafted the 1965 legislation was to provide some kind of health insurance for older people without busting the budget. To achieve this end, they decided to distinguish between things that are medical (which Medicare would ostensibly cover) and things that are not (which it wouldn’t). What that distinction has meant is that housing, transportation, diet, and all kinds of other nominally social goods are off limits for Medicare coverage. A new study by Elizabeth Bradley and her colleagues at Yale shows just how arbitrary—and often counterproductive—such a conceptual divide actually is.

Following up on their groundbreaking work in which they showed that countries with higher social service spending relative to health care spending had better health outcomes, the study team compared the performance of the 50 states (and the District of Columbia) over a 10-year period, from 2000-2009. They defined the extent of each state’s investment in social services by calculating the ratio of social service plus public health spending (on education, income support, nutritional assistance, housing, transportation, and the environment) to the state’s total government health care spending (Medicare plus Medicaid). Then they examined the relationship between this ratio and eight health outcomes (including the percent of the population that is obese, has asthma, or has functional limitations, and mortality rates for heart attack, lung cancer, and diabetes). What they found is that states with higher ratios of social to health spending had significantly better health outcomes (in 7 of the 8 domains).

It's striking that the variability in spending on health care (as a percentage of GDP) across the states is considerable, ranging from less than 4 percent in Colorado, Utah, and Wyoming to nearly 10 percent in Maine, West Virginia, and Missouri. Likewise, the variability in spending on social services and public health is dramatic, going from about 12 percent to over 20 percent. The net effect is that the allocation of resources between social services and health care differs substantially from one part of the country to the next.

It’s a complicated study and I’m sure that methodology mavens will have a field day with it. But the attempt to assess the contribution of social supports to outcomes is so reasonable and the results are so striking that we have to take very seriously the idea that social factors are a major determinant of health and well-being. I’m convinced this is particularly true in older people, whose quality of life is at least as affected by where they live and their ability to find meaning in life as it is by their physical ailments. I suspect that this study is as important as work by Michael Marmot showing that health worsens as people descend the social ladder—not just because of income inequality, but also because of discrepancies in social status. If we want to foster good health, which the World Health Organization defines as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity,” we need to focus on relationships and housing as well as on drugs and devices. And for older people, that may mean user-friendly computers and better assisted living facilities rather than a left ventricular assist device or a new monoclonal antibody.