How Much Does Healthcare Influence Longevity?

Healthcare is only one of several factors that affect longevity in the United States, a new study reaffirms. Behavioral and social factors have much more influence.

Robert Kaplan, PhD, and Arnold Milstein, MD, MPH, from Stanford University School of Medicine's Clinical Excellence Research Center in California, tested how much healthcare affects the risk for premature death using four different research methods and data sets.

All four methods yielded the same conclusion: Healthcare accounts for between 5% and 15% (roughly 10%) of variation in premature death, whereas behavioral and social factors account for 16% to 65%.

The authors report their findings in the May/June issue of Annals of Family Medicine.

The authors suggest that current healthcare policy and spending in the United States are misguided because they're based on the assumption that focusing heavily on medical care is the key to improving outcomes and boosting longevity.

"A lot of the modeling analyses make the assumption that essentially 100% of the life expectancy is related to access to medical care," Kaplan told Medscape Medical News. "Even the most sophisticated modeling analyses make assumptions like at least half of the variability in life expectancy is medical care related."

The 10% that medical care contributes to longevity is important, Kaplan emphasized, and the results do not suggest the United States should not invest in medical care.

"But if our goal is to have longer, healthier lives, we have to go beyond traditional medicine, because most of what determines life expectancy is outside the healthcare system," he said.

Joshua Sharfstein, MD, vice dean for public policy at Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, agrees with Kaplan and Milstein that the popular perception is that healthcare is everything and that the US underinvests in things that could produce important results.

Two fundamental pieces are missing from current policy and spending, he says.

First, the country needs to better address inequality, particularly in safe housing and nutritious food, he told Medscape Medical News.

But investment also needs to be made in programs that motivate and support health.

"Other countries have a much stronger safety net," Sharfstein said. "We shouldn't be surprised that their health outcomes are better and their life expectancies are longer."

Sharfstein said changing the direction on healthcare policy has to start with changing the conversation.

"We need national dialogue not just on healthcare reform or healthcare spending but on health," Sharfstein said. "In the end, what we want is healthy community with people leading healthy, productive lives. There's very little discussion about that compared to where the money's going to go."

Other Countries Spend More on Nonmedical Components

In their article, Kaplan and Milstein cite a book by Elizabeth Bradley and Lauren Taylor in which the authors compare the amount the United States spends on nonmedical social services with the amount other wealthy Organisation for Economic Co-operation and Development (OECD) countries spend on those services.

They found that the other wealthy OECD countries spent an average of $2 on nonmedical social services, such as education and social service programs, for every $1 spent on medical care. By contrast, the United States spends about 55 cents for nonmedical social services for each $1 spent on medical care.

"Although we spend much more than these other countries on medical care, what we spend on services that might improve life expectancy is about in the middle of distribution among wealthy countries," Kaplan said.

Kaplan said the Chronic Care Act that was enacted last year is a step toward shifting spending in the right direction.

That legislation allows Medicare Advantage plans to cover interventions beyond those considered traditional healthcare, such as bathroom grab bars or wheelchair ramps or additions to homes to make them safer.

"Due to a longer duration of health benefit, extending similar coverage policies to pregnant women and children enrolled in Medicaid may generate even higher yields," the study authors write.

What Can Physicians Do?

In an accompanying editorial, Steven H. Woolf, MD, MPH, Department of Family Medicine and Population Health and Center on Society and Health, Virginia Commonwealth University, Richmond, identifies five major contributors to health: healthcare, public policy, health behaviors, the physical and social environment, and socioeconomic status.

He points out that better health cannot depend on any one sector, "because the sectors are interconnected: people cannot access jobs or health care, for example, without stable housing, transportation, and child care."

Reversing the trend of spending only 55 cents on the dollar for nonmedical services is unlikely in the current climate in Washington, DC, and in many states, so change is more likely to occur at the local level, Woolf writes.

He says individual physicians can help broaden the focus of medical care by obtaining more information about a patient's circumstances and designing care plans that can be realistically implemented. If a clinician knows that a patient can't read English or can't afford medications, for instance, the clinician can help find a translator or suggest less expensive medications, he explains.

Physicians and nurses can also use their trusted voice in the community to advocate for investment in education or public transportation or for livable wages, and they can join professional societies that are taking stances on social change.

Woolf writes that an example of the misalignment of values with current healthcare policy and spending is exemplified in a quote by organizers of the 2017 Medicalization of Poverty Symposium: "We spend inordinate amounts of money and other resources to address healthcare needs brought on by poverty instead of providing for the tangible needs of the poor before illness strikes."

Kaplan is author of More than Medicine: The Broken Promise of American Health. Milstein and Woolf report no relevant financial relationships. Sharfstein is an adviser with Sachs Policy Group in New York City, where he helps organizations prepare for healthcare transformation.

Ann Fam Med. Published online May 13, 2019. Abstract, Editorial

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