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Promoting Health, Not Just Health Care

By David Orentlicher

Once again this past Thursday, the Democratic presidential candidate debate began on the topic of health care reform, and moderator George Stephanopoulos quickly steered the discussion to what he termed “the heart” of the debate. Should the United States increase access to care by building on the Affordable Care Act (ACA) or by replacing ACA with a single-payer, Medicare-for-All system?

While this is an important question, there is an even more important question for the candidates to discuss. We need to hear them talk more about health than about health care.

We’ve known for a long time that preventing disease is more important than treating it, and that health care plays a relatively small role in determining a person’s health. If candidates want to have a real impact on the health of Americans, they should be talking about their plans to address the social determinants of health. How will they make sure every community has clean water, good schools, safe workplaces, and other hallmarks of healthy communities?

And the most important social determinant that candidates should be talking about with regard to health is income inequality. For while it is commonly thought that access to health care makes for good health, that’s not the case. It is true that the uninsured are sicker than the insured, but it’s not because they are uninsured. It’s because they are poor.

Simply giving the indigent health insurance won’t change that very much. The life expectancy of lower-income persons is not correlated with the amount of health care that they receive, or even with the quality of care that they receive. Nor do their mortality rates change when they become eligible for Medicare. Rather, their health improves when their economic status improves. Income has a greater effect on health than health does on income.

Everyone should have access to good health care, but what people need even more are policies that will save them from getting sick in the first place. When it comes to ensuring that people are healthy, universal access to a good income is much more important than universal access to health care.


David Orentlicher, MD, JD, is the Judge Jack and Lulu Lehman Professor at UNLV William S. Boyd School of Law, Director of the UNLV Health Law Program, and a Member of the Nevada Assembly.

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