Necessary But Not Sufficient: Why Health Care Alone Cannot Improve Population Health and Reduce Health Inequities

Steven H. Woolf

doi:10.1370/afm.2395

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Sometimes less is more
Alan Katz

Published on: 20 May 2019
Author response Re:Proposal for Change
Steven Woolf

Published on: 17 May 2019
Proposal for Change
Kevin T Bokun

Published on: 16 May 2019

Published on: (20 May 2019)
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Sometimes less is more
Alan Katz, Family physician
Thank you for this insightful editorial. It is rare to read editorials in medical journals that recognize the limits of the impact of clinical care on the health of the population. Dr Woolf makes a clear rationale case for a broader understanding of health status that should challenge us all to reflect on our contributions to the problem and potential solutions.
As a Canadian supporter of the Canadian universal...
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Thank you for this insightful editorial. It is rare to read editorials in medical journals that recognize the limits of the impact of clinical care on the health of the population. Dr Woolf makes a clear rationale case for a broader understanding of health status that should challenge us all to reflect on our contributions to the problem and potential solutions.
As a Canadian supporter of the Canadian universal healthcare system, my initial response to the comparisons in health status between our 2 nations is to blame the US healthcare delivery models (clearly not a single system) for the difference. It is true that the health of Canadians is improving, with life expectancy increasing and premature mortality rates decreasing. But if we agree that only about 10% of this due to healthcare service provision we need to consider the other causes of the difference in direction in health status our two countries are taking. So as family doctors what can we do to respond?
Family medicine was called a "counter culture" by Lynn Stevens in the early years of the discipline. The pioneers of family medicine saw themselves as taking unorthodox positions matched by bold actions. If we really want to take action that addresses the underlying issues (primarily inequities in society) we need to be bold. We need to recognize the message the Woolf's editorial is really pointing to and step out of our comfort zone of trying to find clinical solutions to non-clinical problems.
Woolf does recognize this but I think the conclusion to the editorial does not reflect the discussion. The question is, can we take the kind of actions required for change or is this too threatening.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (17 May 2019)
Page navigation anchor for Author response Re:Proposal for Change
Author response Re:Proposal for Change
Steven Woolf, Director Emeritus
I thank Dr. Bokun for his comments, which appear to be a reaction to the closing lines of my editorial, in which I noted that although "universal health care insurance coverage" and "access to primary care" are vital, neither will be adequate to move the needle on population health. The reference to universal health insurance was meant to avoid the subject of how we get there--neither Medicare nor Medicaid was mentioned-...
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I thank Dr. Bokun for his comments, which appear to be a reaction to the closing lines of my editorial, in which I noted that although "universal health care insurance coverage" and "access to primary care" are vital, neither will be adequate to move the needle on population health. The reference to universal health insurance was meant to avoid the subject of how we get there--neither Medicare nor Medicaid was mentioned--and my intent was to skirt the complex debate about the pros and cons of the government versus the private sector in finding a universal solution.
Dr. Bokun rightly notes that access to care is a nuanced issue with many dimensions. I refer readers to the many excellent articles in this journal and others that have studied these issues in detail. My larger point, however, was that even a perfect health care system cannot solve problems with origins outside the clinic. While I agree with Dr. Bokun that "membership-based practices have been of great service to many people in all socioeconomic strata," studies of integrated health systems still show a gradient in patients' health outcomes across the socioeconomic gradient--despite similar levels of access to care.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (16 May 2019)
Page navigation anchor for Proposal for Change
Proposal for Change
Kevin T Bokun, Medical Student
Dr. Woolf lines out several problems plaguing our nation today which include differences in healthcare among socioeconomic groups and a lack of investing in poor and underserved areas. These are real issues that affect many people.
What gives me pause is that the author calls for an expansion of insurance coverage through the federal government. Though I agree that this solution might work, there are still many...
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Dr. Woolf lines out several problems plaguing our nation today which include differences in healthcare among socioeconomic groups and a lack of investing in poor and underserved areas. These are real issues that affect many people.
What gives me pause is that the author calls for an expansion of insurance coverage through the federal government. Though I agree that this solution might work, there are still many patients on Medicare and Medicaid who cannot afford medication or to see their physician. "Access to healthcare" is also misleading because studies have shown that those who live the closest to healthcare facilities have a further progressed disease course than those who live farther.
Government-provided insurance may sound helpful, but it is simply insufficient for many people. Cash-based and membership-based practices have been of great service to many people in all socioeconomic strata. If there were fewer restrictions and difficulties getting into these communities (restrictions and inefficiencies as with these insurances), many doctors and healthcare workers would gladly work in underserved areas. Insurance and the increasing influence they have has continually driven private practice out of existence. Instead of applying more restrictions and difficulties, allowing physicians to work directly for the people would be of greater benefit.
I don't believe the desire to expand Medicare and Medicaid is malicious. I simply think it does not accomplish what it intends to. The stress and inefficiencies put on physicians by insurance companies and larger healthcare systems have lead to an increase in physician suicide and earlier retirement.
I agree that these issues presented in this article are serious, and it says a great deal about a nation with respect to how they treat their poor. I simply do not agree with the solution. Though well-intentioned, expanding insurance coverage has not proved to help health outcomes overall and only makes it more difficult for doctors to do their job.
Competing interests: None declared
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Competing Interests: None declared.