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The Public Health Lens and Health Care Reform

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foxThis post was written by Jacqueline Fox, JD, LLM, Associate Professor, School of Law, University of South Carolina. Any questions or comments can be directed to  

The Affordable Care Act is huge, and covers many, many things.  The focus of public debate in recent months has been on the parts related to personal insurance, especially for individuals who don’t get care from their employers.  People seem puzzled, frightened, and angered by many of the changes.  I thought it might help to clarify what the public health thinking is that has gone into this new structure. 

Public health has a singular lens that it uses to look at the world.  The goal is to improve mortality and morbidity, without intruding too much on individual autonomy.  This sounds a bit dry, but just means that we want to reduce death and sickness, while leaving people with the liberty to have good, meaningful lives of their own making.  People in public health have their own ideas about the best political structure, and who should be making decisions about war, or taxes, or anything else, but these preferences don’t change what public health, itself, does or cares about.  

So, looking at health insurance, public health has some ideas about what works best.  First, cover the preventive services that have a big impact on population health overall.  By making them super cheap for people to access, we hope people will choose to get early care, preventing big diseases and unnecessary death from occurring.  This is meant to balance freedom (you get to choose whether or not you get preventive care) with outcomes (if we make it easy for you, you are more likely to do it). 

Second, cover the big problems that human frailty make inevitable.  Big things cost a crazy amount of money to handle, money that almost nobody has in their own hands.  This is why policies should have no caps on them, and should kick in at 100% of cost when costs get to the range that they do when someone is terribly sick or injured.  This reduces mortality for populations, because people are more likely to get care that can actually cure them if it is free to them and paid for by a pool of funds.  If someone is so sick that they cannot be healed, we can extend life and reduce suffering through the same policies.

Third, keep the system as inexpensive as is realistically possible.  If no one can actually handle the costs, the system has failed.  It is hard, but some balance has to be made about individual and societal resource allocations for health care.  This requires spreading the cost among people in a way that individuals can bear while still achieving the best coverage for the population.  This is why people who have high incomes have to pay more for their policies, and why there is a pretty big pile of money that most people will have to pay for co-payments and deductibles until their personal out of pocket limit is reached.  Note that public health does not dictate that you be happy about paying $300 a month for your part in this system, or happy that your deductible and copayments can reach $12,000 in a bad year.  But the gross calculations say you can still meet your basic needs while doing so, and will not be forced into bankruptcy, losing your home and savings, if you have a particularly bad year of illness or injury. 

There are some other parts to this that the public health lens can also explain.  For example, mandatory coverage for birth control is included.  Everyone I know in public health wants every birth to be planned, voluntary, and healthy.  Birth control is an essential part of this, allowing people to maintain their relationships and not have children unless they choose to.  Everything in public health is better if pregnancy and birth are handled properly.  Children, as a population, have far healthier, more productive lives if their parents want them and have planned for them. Women have far better outcomes, physically and economically, if they can control this part of their lives.  In order to balance personal freedom with this policy goal, people can make their own decisions about procreative choices.  Take birth control, don’t take birth control, have genetic testing or not, be celibate or have multiple partners, these choices are all left to the individual (and, of course, their partners!).  Providing birth control for free is meant to make it easier for people to use it properly, with the hope that planning becomes more widespread.  It is less expensive for an insurance plan to cover birth control than to not do so, since pregnancy is expensive to pay for, so this was actually an easy choice for inclusion.  From a public health perspective, the feelings of employers about this benefit are entirely irrelevant.  Because public health values individual control of health choices, employers should not play a role in making a personal decision about using birth control.

Another issue that seems to upset people is including maternity benefits in insurance plans while at the same time leveling costs for men and women.  People who cannot or choose not to have children must pay the same amount into the pool as people who want to and can have children.  From a public health perspective, the human race continues through procreation, and so the burden should be equally spread to everyone in the human race.  The focus here is the United States, and so that group should equally share that burden. 

I guess, stepping back, public health looks remarkably politically naive.  Telling people to pay more for insurance will make them angry. Telling employers to cover birth control will upset those who do not want their employees using birth control.  Choosing full coverage for preventive services while having people shoulder a big chunk of mid-level costs is a big decision that effects people’s personal choices about how to spend their money, limiting the kinds of sacrifices they might be willing to make in their own lives.  The pregnancy coverage is not quite as dramatic, simply because Medicaid currently covers most pregnancy and delivery costs, so we pay for this with our taxes anyway, but still, some are deeply offended at the thought of subsidizing women or supporting child bearers. 

I promise you, public health, while forced to work within a political system, is happy leaving that set of problems to everyone else.  If anger reaches a point where people do not make good choices, then public health gets concerned again, but in terms of formulating ideas, the goals are simple.  Improve health outcomes.  Protect freedom to make important choices.  Balance everything to maximize the best outcome.  Nothing is ever perfect, sacrifices are always being made, keep your eye on moving the ball forward.  There is room for robust political debate over every aspect of our society, but the public health goals of health insurance reform were not formulated in political discourse. They were formulated looking at statistical data about how to improve population health. 

There are other problems that have emerged besides upset over these structural changes.  The complexity of choices, combined with a malfunctioning system, has caused chaos.  Some insurance companies and hospital systems have chosen to send grossly misleading letters to members and patients, claiming inaccurately that “the law” forces them to immediately cancel policies and narrow patient access to physicians and hospitals.  Other plans have chosen to create absurdly small networks of providers and hospitals, striving to control costs while ignoring the inevitable political blowback that will result in states stepping in and forcing them to expand.  Medicaid expansion has been turned down by many states, leading to a terribly unfair result where people who earn the poverty level get nothing, whereas those just above it suddenly get it all.  I believe that all of this can be resolved, and will be resolved, over time, but the entirely unnecessary fear, anxiety, distrust, and confusion is painful for everyone. 

Public health has accomplished great things for human kind, and keeps trudging along, striving to always improve human existence.  Some of the political choices in healthcare reform may bother you, and these should be the subjects of rigorous, ongoing public debate.  May I ask, however, that we have that debate while keeping an eye on the goals we all seek in public health, and try to formulate compromises that move us forward not just to a happier constituency, but to a healthier one? 

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