Experts in the fight against poverty, like anyone, can sometimes miss the forest for the trees.
That may be happening in the increasingly heated debate swirling around the global movement for Universal Health Coverage. The gist of this global push, led by folks at the World Bank, Rockefeller Foundation and others, is to ensure everyone around the world has access to basic and preventative health services.
Now, people disagree on what is precisely meant by the term ‘universal health coverage,’ aka UHC, but the assumption is that increasing access to essential health care will improve health outcomes and also economic stability – especially for the poor.
Sounds like a good assumption, eh? Not so fast.
Experts in health policy, aid and development say there is insufficient evidence to support the claim that simply increasing access to services improves health outcomes. Which services are we talking about? What outcomes are the best measures? What do we mean by access? Experts say we need to better define terms and test assumptions before taking steps to improve access to health.
A post this week Is Free Health Care Good for Health? from Amanda Glassman, a health policy expert at the DC-based think tank Center for Global Development, offers a glimpse into this debate among experts.
Glassman was bouncing off a recent skirmish in the war of words, which I also wrote about last week in the post Data Love. This debate was prompted by a one-year study in Ghana that determined there was ‘no overall health impact’ from making access to health care ‘free.’ Writes Glassman:
Like insurance, removing user fees reduces the direct costs of health care. But reducing the direct costs of care generally hasn’t – on its own – improved health. Free care or insurance thus seems a necessary but not a sufficient condition for improving health outcomes.
That’s true, said Rodrigo Moreno-Serra, a health policy economist from the Imperial College London. But it would be a mistake, Moreno-Serra contends, to extrapolate from the lack of positive findings to conclude this then means that there is no health benefit to removing financial barriers to health. There is such evidence, he says.
“Our own research shows that improving access to health services, including broadening coverage and reducing financial barriers, does lead to improved health outcomes – at least for children under 5 (years),” he said. Moreno-Serra spoke in Seattle Wednesday at the Institute for Health Metrics and Evaluation on UHC, equity and health outcomes.
He presented his team’s findings, not yet published, of an analysis of health and equity factors (or social determinants of health) obtained from 160 countries over a period of 17 years. The researchers specifically looked at how ‘pooling’ health expenditures – funding health by virtue of taxes, mostly – impacted under-5 child mortality rates.
The equity or social determinant factors were included to make sure they were measuring other forces that impact health such as access to clean water, sanitation, skilled nursing for birth, primary school enrollment and even things like CO2 emissions (which can be both a health threat and a measure of economic growth), governance and other perhaps less than obvious drivers of health.
What did Moreno-Serra and his colleagues discover?
“For every $10 of increased health spending, we saw 1.4 per 1,000 fewer deaths for children under age 5,” he said.
That’s a health benefit. But what difference does it make that the health spending was ‘pooled’ – as opposed to getting paid for by individuals out-of-pocket or through some more individualized private insurance scheme?
“Pooling is critical,” Moreno-Serra said. The point of the study, he explained, was to inform the debate about how best to achieve universal health coverage. With the poor especially, he said it’s pretty well established that increased out-of-pocket costs diminishes their use of health services – at least until it becomes an unavoidable crisis – which most experts agree will likely undermine health.
“But it is true that it is difficult to demonstrate health outcomes,” Moreno-Serra said. One look at the slide to the left, from his talk in Seattle, hints at the complexity of trying to nail down hard-and-fast proof that reducing barriers to health access clearly improves health.
Glassman, in an email response, said Moreno-Serra’s study is less experimental and able to attribute causation than the Ghana study because the Imperial College gang’s methods were “a cross-country regression that shows an association between public subsidies for health and health status” – and ultimately addressing a different question. Uh, I don’t really understand that ….
Suffice it to say Glassman is neither arguing against the potential benefits of reducing or eliminating financial barriers to health care. Nor is she advocating on behalf of the authors of the Ghana report.
“My point is that the services themselves and their quality seem to be most important for impact,” she said.
Okay, but I’m simple and I just want to know if it is good to make health care ‘free’ (more accurately, paid for by taxes as opposed to individual consumers) or not. So I asked Moreno-Serra: Does your study show a health benefit to making health care free?
“Yes, at least for child mortality under 5,” he answered. And child mortality, he said, is widely regarded as a fairly good proxy for overall health trends. Moreno-Serra then went on, much like Glassman, to try to explain to me the challenges of econometrics, health trends, reverse causality and ….
Clearly, the experts believe we need more studies. Of course they do. That’s a given for the expert class, like death and taxes for the rest of us.
But meanwhile, poor people actually die from lack of access to care. Meanwhile, the United States, like much of the developing world, has been engaged in a huge – some might say brutal – experiment that some may think is pretty solid evidence of what not to do.
In the US and most poor countries, unlike most of the rest of the civilized world, access to basic health care is not treated as an entitlement or basic right. It is instead treated mostly as a commodity, as something we choose to buy. So-called Obamacare doesn’t really change this since it is aimed at making us buy insurance and, in return, promising to reduce some of the abuses inherent in the marketplace approach to health services.
Moreno-Serra said he agrees there is a dearth of strong compelling data to support any unequivocal claim that improving access to health services by reducing financial barriers clearly results in improved health outcomes. That said, he contends there’s plenty of research – his and others – to indicate this is the case, at least for certain easier-to-measure outcomes like child mortality.
Moreno-Serra said the one-year Ghana study – and even the Oregon study, in his opinion – aren’t really powerful or precise enough for anyone to be arguing that they show free health care does not improve health outcomes. All they do is fail to show that reducing financial barriers and increasing access to care improves health. It’s a failure of the study, he said, not evidence that making health care free makes no difference.
Meanwhile, there’s plenty of data that shows medical bankruptcies are a leading cause of impoverishment here, as in the developing world. But that’s not a direct health outome. So let’s look at American population health indicators. Despite spending way more than anyone else on health care, Americans have abysmal population health indicators and sometimes rank right down there with poor countries overall.
Do financial barriers to health care make people less healthy? Seems like the evidence there is pretty strong, even if it can’t be proven to the satisfaction of some experts.
Given the financial, political and logistical challenge of expanding access to health care worldwide, one may well wonder if these expert debates are advancing our knowledge or only serving the interests of inertia.