We need to think more holistically about the health-care debate

As a public health nurse, I am always intrigued by our nation’s endemic health-care policy debate, especially as it heats up this election season. I am one of the 69 percent of Americans who rated health care as a top policy concern for 2019, and I am listening closely to what each of the 2020 presidential candidates have to say on the issue.

The Trump administration has so far been unsuccessful in its mission to repeal the Affordable Care Act (ACA), but they will continue to try and dismantle it through their first term and potential re-election as evidenced by their latest move this week, when the Justice Department asked a federal appeals court to invalidate the entire law.

{mosads}Meanwhile, House Democrats unveiled an incremental proposal this week that would build on the ACA, while Democratic presidential hopefuls take various stances on health care from “Medicare for all” to more incremental changes that would allow more individuals to buy into government-run health-care plans (e.g., lowering the age for Medicare eligibility to 55, reinstating the public option that was gutted from the Affordable Care Act).

With Americans paying more for health-care than any other developed nation and still having worse health outcomes, the debate about how to provide affordable and accessible health care is unarguably critical and must continue. We absolutely must do something about the high prices we pay for prescription drugs, medical devices, and various other health-care expenses that are higher in the U.S. than elsewhere. As someone who was denied health insurance in my early 20s due to my “pre-existing condition” of Celiac Disease, I fully understand the fear of returning to a time when those who need health insurance the most cannot get it.

However, I would like to see us take a more holistic approach in our policy debates about caring for the health of our nation by following the lead of the American Public Health Association, National Academies of Medicine, European Union, and state and local governments around the U.S. who have, for many years now, championed a Health in All Policies approach to protect and improve the health of individuals, communities, and populations. From this perspective, health considerations are taken into account across sectors of policymaking — not just access to health care — such as transportation policy, housing policy, water policy, and urban planning.

When we limit our thinking about the health of our nation to a conversation about health care, we are missing upwards of 80 percent of the factors that actually contribute to our health. According to the County Health Rankings, only about 20 percent of our health can be credited to access to health care, while 40 percent can be credited to social and economic factors (e.g., employment, income), 30 percent to health behaviors (e.g., sedentary lifestyles, drug and alcohol use), and 10 percent to environmental factors (e.g., safe and accessible sidewalks, air and water pollution).

This other 80 percent is collectively known by public health professionals as the social determinants of health, and includes factors such as access to educational, economic, and job opportunities, public safety, social support, residential segregation, access to parks and sidewalks, indoor and outdoor air quality, and weather.

If we look at the list of other factors that Americans are concerned about, many if not all of them have direct links to our health. For example, the economy was cited as American’s top policy concern in 2019.

Studies repeatedly show that, from the top to the bottom of society, those with greater income and wealth experience better health than those with less income and wealth. Money provides the security of material benefits, healthier living conditions, less chronic stress, and, of course, access to health care when we do get sick. We also know that countries with greater income inequality, such as the U.S., experience worse health.

Why, then, when we discuss economic policy on the campaign trail and develop it in the halls of Congress, do we not also analyze and discuss the health implications of these policies? Particularly when the majority of Republicans and Democrats are concerned about health care (and, I presume, health).

What happens to our health when tax breaks are given to the already wealthy, while there is no state in the U.S. where a full-time minimum wage worker can afford a two bedroom apartment? Why, in all the media coverage of Sen. Bernie Sanders (I-Vt.) discussing income inequality, do I not hear how inequality is related to health?

Education is also a top concern for Americans across the political spectrum, and we rightfully hear much about how we need to find a solution to the student loan debt that is crushing Americans and impacting many life decisions including homeownership, marriage, child rearing, and saving for retirement.

We know that those with higher educational attainment (e.g., college graduates), on average, experience better health that those with lower levels of educational attainment (e.g., high school graduates) through several mechanisms, including obtaining jobs that provide better salaries and benefits (e.g., vacation time, health insurance) and engaging in fewer unhealthy behaviors. Why, then, when candidates and lawmakers discuss and develop educational policy do they not connect the dots to health?

From the economy to education to the environment to public safety and all topics in between, all policy roads lead to health. Without our health, we are impaired in our abilities to work, learn, play, or participate in our family and social networks. We must move our policy dialogue from a siloed one of sick care to a holistic one of prevention.

While it is currently true that preventing illness is not necessarily a money maker for our for profit health-care industry, we must consider how profitable a health population is for other sectors and consider this across all sectors of policymaking.

While implementing a true “Health in All Policies” approach complete with cross-sector collaboration and ongoing analysis will take time and dedication, we can at least start expanding our basic dialogue about health in all policies on the campaign trail, in the media, and around our kitchen tables.

Karen Johnson is a public health nurse and associate professor from the School of Nursing at the University of Texas at Austin and a Public Voices fellow of the Op-Ed Project.