Now that as many as 6.4 million low- and middle-income Americans across 34 states have health insurance as a result of the Affordable Care Act, it's worth asking this question: When does health insurance turn into actual health?
It's a legitimate question because the impact of health insurance on health has been shown to be less impressive than we might wish. At least one study out of Massachusetts, for instance, has demonstrated reductions in mortality associated with insurance status, while other studies out of Oregon show only modest reductions in mental health disease burden. So how much health have we really gained nationwide from the ACA’s insurance expansion? It remains to be seen.
In the meantime, it may be time to turn our collective attention to a slightly different question: Where else in Americans’ lives might we find more substantive ways to improve health?
The Blue Cross Blue Shield of Massachusetts Foundation recently released a report which might help answer some of these questions. Researchers, led by Elizabeth H. Bradley, Ph.D., of the Yale School of Public Health, reviewed available literature on the health improvements and cost reductions associated with interventions beyond the scope of traditional medical care. The authors point to the strong evidence that increased investment in selected social services — housing support, nutritional assistance, case management for low-income families, children with asthma and seniors — as well as various models of partnership between health care and social services can offer substantial health benefits and reduce health care costs for targeted populations. In other words, the research demonstrates that when these interventions are targeted at high-cost, high-need patients, the results can make a huge difference in people's lives, and also save the system money.
As a longtime primary care physician working in an urban hospital, my patients (often underserved families) confirm this empirical evidence. Here's just one example:
The mother of a family has been coming to me for years. Her body and medical chart are riddled with multiple diagnoses: high blood pressure, chronic pain, anxiety, depression, high sugars and obesity, for which she takes numerous medications. Her life was chaotic — homeless with two young girls, a constant state of fighting in shelters, hyper vigilance for her girls’ safety and a state of depression that was only getting darker. Her girls also started getting their care through me and though they were more resilient in this state of constant flux and stress, their own lives were slowly falling apart in the long shadows of their mother’s mental illness. As a physician, it was hard to know where to start to get this family back to better health. As a mother myself and a public health advocate, I knew I had to start with the mother and her primary concerns.
And so in every visit we addressed her housing issues — filling out form after form, making calls and writing letters — alongside her other medical issues. Last year, she came in elated. She finally had secured housing. The next several visits were a flurry of pictures — new bedrooms and her smiling girls. But far beyond the pictures, there was a transformation. My patient started seeing a therapist again, taking her psychiatric medications, exercising and taking better care of her body. Her daughters also came to see me in the months that followed and it was if they were plants in the sun, finally growing back into their girlhoods. The oldest was just starting to dream about college. And though I am not naïve enough to think that their secure housing will make their health consistently good, it shifted the landscape entirely. Enough that they were able to start taking care of their lives and each other.
In addition, o ther types of social service investments, including income support and early childhood education, were found to improve selected health outcomes but were lacking rigorous cost analyses, according to the Blue Cross study.
Three Massachusetts-based programs stood out as demonstrating an impact on costs, outcomes or both: a housing model for chronically homeless individuals known as Housing First, a progressive managed care organization caring for people who are dually eligible for Medicare and Medicaid called Commonwealth Care Alliance, and a community outreach and preventative health screening program run out of Harvard Medical School, called the Family Van.
What is innovative of about all three models is that they take seriously the question of, what do people really need to be well? For some people, the answer may be a safe and stable place to live. For others, it may be an air filter for the home. In others, it may be a convenient opportunity to discuss health care risks with a qualified provider near to their homes.
These findings may come as little surprise to those familiar with the so-called social determinants of health literature, which is built around an investigation of “the social, behavioral, and environmental influences on one’s health.” Behind this idea is research suggesting that up to 60 percent of health may be directly related to social, behavior and environmental influences and as little as 20 percent of health may be being determined by access and quality to health care. (The remainder is generally attributed to genetics.)
This framework has recently gained wider attention in the wake of policy recognition that a large proportion of health care costs are driven by a small population of high users, whose core needs may ultimately lie outside the scope of services that even the best health care system can deliver. The success of programs like Boston-based Health Leads, Medical-Legal Partnerships and Iora Health are further confirmation that providing patient-centered care for vulnerable populations is finally making good financial sense.
The continuing implementation of the ACA serves as a reminder that progress in the U.S. health care landscape, however incremental, is possible. Of course, much remains to be done to continue to improve the health of the American population. The ACA was intentional about trying to reform insurance markets and the health care delivery system, but it is time to also look beyond the medical system for sources of change. Now the nation is finally insured, isn’t time that we start to advocate for getting our health needs addressed?
Dr. Katherine Gergen Barnett is a family physician, educator and researcher at Boston Medical Center. Lauren A. Taylor is co-author of "The American Health Care Paradox" and a doctoral student in health policy and management at Harvard University.