Social determinants of health such as crime, quality of education, and transportation mobility play a major role in the health expectations of communities, particularly around chronic conditions. In order for medical interventions to be most effective, public policy must support an overall reduction in the barriers certain communities face to health improvement. We know that in the United States, weight-related conditions such as Type 2 Diabetes, Hyptertension, or Obesity are not medical problems, per se. We know, medically, how to mitigate the effect of such conditions on a patient’s quality of life. The problem of a rising obesity-rate and its subsequent impact on comorbid conditions is largely behavioral. What makes the behavioral component so difficult to address is that even though there have been historically clear relationships between obesity and poverty, the overall rate of obesity has risen such that it is becoming a characteristic of the overall population rather than just a product of economic disparity.
As a result, the tired argument of blaming the poor for their own issues is a non-starter. Even simply blaming the existence of food deserts or the unaffordability of healthy foods misses more foundational issues. The whole of the population is susceptible to obesity and obesity-related chronic conditions, with apparently different factors driving obesity for different segments. Recent studies have shown that by the early 2000’s, high income earners were the demograpic that experienced the fastest growth in obesity, which should encourage a more holistic look at the behavioral factors that might affect such a trend.
Using an urban planning simulator like Sim City, we can examine the civic factors of urban design such as transportation choices, work preferences, zoning, and planned development to better understand the aspects of public policy themselves that increase behavioral risk for obesity.
While Sim City doesn’t really tackle microeconomics like car ownership or household consumption choices, it does provide a good model for conceptualizing how public planning decisions drive macro behaviors.
Take zoning – which in Sim City is limited to Residential, Commercial, and Industrial. Placement of zones when first building a city has long term consequences on traffic patterns, prevalence of air and water pollution, land value/income demographics, quality of public services such as education, and of course citizen health.
In the example above, the green zones represent Residential zoning, the yellow Industrial zoning, and the purple Commercial zoning. This city has multiple avenues surrounding the commercial district in the center, allowing a high volume of traffic to funnel in to and from the surrounding Residential and Industrial Zones. Much like real life, high density development without appropriate scaling of the capacity of roads will result in traffic congestion.
In the picture above, just like in Google Maps, red roads mean heavy traffic, while green roads mean clear traffic. And because cars emit carbon monoxide exhaust, heavy congestion predictably results in air pollution
As you can see, the heavy traffic roads also have higher pollution. The heavy pollution at the bottom right of the screen also comes from the industrial zone.
Based on the preferences of the citizens in this Sim City town, we can see that the car is the favored form of transportation. Wealthier citizens are willing to put up with long commute times before switching to alternatives if their place of work is beyond a short walk away.
The net result is that in spite of high quality hospitals nearby (the bright green buildings), the overall population health in the low-income residential areas nearby the commercial district is disappointing – where green is healthy and red is unhealthy.
These same concepts apply in real life as well, where the way citizens respond to urban planning and public policy leads to health hindering behaviors. Long commutes by car to jobs that involve sitting for most of the day result in worse health for the commuters, while the pollution caused by emissions from heavy traffic negatively impact the health of citizens throughout the region. Sprawl of the city population out to suburbs that causes the long commutes also increases the expense of providing public services like police, education, and utilities, straining the city’s ability to equitably serve the whole population.
Without even touching issues of food insecurity or food deserts we can see the complicated relationship between public policy and health.
Applying concepts to reality
Sim City is just a simulator, but it still provides us with a window for the interconnected nature of different public policies. Our understanding of policy is often dominated by “single issue” special interests that frequently leverage emotional appeals to gain political legitimacy. However, what we can learn from applying concepts from games like Sim city onto our empirical experience is that no matter how singular the intended effect, all policies have ramifications.
More importantly, these ramifications drive behaviors of citizens at a micro and macro level. The decision to build a new retail development in a certain part of town will affect traffic, strain water/power infrastructure, and may result in economic stress for certain portions of the existing residents. All of these effects will have some measurable impact on population health and health care expenditures. Given that the physical and mental health of citizens is central to maintaining productivity, reducing crime, and supporting an overall high quality of life, health should naturally be a central focus of public policy. Questions such as “how will this impact health-related behaviors?” and “how might this affect health-related expenditures?” should be a major consideration by policy-makers when evaluating any new development.
The case for health-driven policy
There are three major arguments in favor of a “health-first” approach to public policy:
1) Our national and local healthcare expenditure is a huge economic problem
2) Government and Payers are shifting responsibility for patient outcomes directly onto care providers (value-based care)
3) Heart attacks and strokes are not partisan issues
1) Our healthcare expenditure is a huge economic problem
Not very many would argue the fact that within the US, from the patients’ perspective, health services are generally not cost effective. When adjusted for Purchasing Power Parity, the US outspends every country in the world per patient. Yet the expenditure is not reflected in health outcomes.
I discuss in another article why life expectancy may not be the best measure of health outcomes, and how we might want to look at measure such as obesity rate instead. But end result is the same; a great many other countries spend far less per person and get much better health outcomes.
Beyond health outcomes, there are significant economic consequences to having an expensive healthcare system that is still ineffective at addressing population health issues such as obesity. For example, obese employees file twice as many worker’s compensation claims as non-obese workers, and a roughly 10-fold increase in loss of workdays (183.63 versus 14.19 per 100 FTEs), medical claims costs ($51 091 versus $7503 per 100 FTEs) and indemnity claims ($59 178 versus $5396 per 100 FTEs). Absenteeism due to obesity-related issues cost employers a total of $153B per year(1 cite) while total obesity related care delivery costs range anywhere from $80B to $120B. Given total health expenditures are roughly $1.4Trillion, that is nearly $1 in $10 spent as a result of obesity.
Another major economic issue is how patients pay for care. Unpaid medical bills are the number 1 cause of personal bankrupcy in the US. Even among patients with health insurance, 10 million adults with year-round insurance will accumulate medical bills that require multiple years to pay off. In today’s climate, a person who suffers a severe accident due to misfortune may potentially end up removed as a participant in the economy as a result of the cost of care. To have patients who have preventable conditions that have gotten out of hand and whose families are paying medical bills for decades, is nothing but pure failure. To what extent this health crisis has stifled our ability to recover from the Great Recession we may never know.
2) The rise of value-based care
In response to the extreme cost inefficiencies of the standard, fee-for-service healthcare model, both private and public payers have been undergoing a philosophical shift over the past several decades. Even before the Accountable Care Act nudged health insurers into an open market, there have been several key drivers that have lead to the disintegration of fee-for-service
- The unsustainability of insurance premiums that have risen much faster than income growth
- The pending insolvency of Medicare/Medicaid at current cost trends
- A chaotic care coordination process that relies on patients knowing how to navigate multiple health systems
Patient advocates and fiscal conservatives are aligned in their incentive to develop new financial models of care that push more risk onto care providers. One such model – the Accountable Care Organization – attempts to establish key metrics on which to evaluate quality of care delivered, and shares cost savings with providers if certain quality and cost standards are met. Many other HMO’s, integrated payer-provider systems, and physician networks are developing other innovations on the traditional reimbursement model that simultaneously seek to improve the quality of outcomes and reduce total cost per patient.
One of the main benefits of the philosophical shift towards value-based care will be the increased data collection across the continuum of care. This will enable vastly improved behavioral and health risk modeling, and allow policy-makers to more accurately predict the health impacts of potential policies.
3) Heart attacks and strokes are not partisan issues (yet)
Unlike vaccines or abortions, no one within the political realm is arguing the science of treating obesity. The near ubiquitous acceptance of unhealthy diet and lack of exercise as core contributors to obesity and obesity-related conditions means that clinicians have room to focus more on medical or behavioral therapy rather than defending science.
Further, because population health is such an integral component of value-based care, care providers and payers are in a unique position to influence dialogue around policy as it affects health. The fact that obesity has not yet been politicized means that clinicians and health administrators can speak about the health impacts of weight-related chronic conditions from a relatively unquestioned position of expertise. This legitimacy is a crucial component of a health-centered public policy.
Whether or not the rest of the political sphere, including lobbyists and other special interests, can be persuaded to subordinate their priorities to citizen health is another matter altogether. They are unlikely to do so if the clinical data predicts negative health impacts from adopting their policy positions. Nonetheless, it remains of utmost economic importance for citizens, care providers, and payers to work together to present compelling arguments for policy-makers to evaluate policy proposals on the short and long term affects on population health.