Matt Yglesias points readers to The Health of Nations by Phillip J. Longman. Longman argues that lifestyle, more than health care, affects mortality and disease. Longman aptly points out that “the health-care system kicks in after most people are already ill,” reflecting the emphasis on treatment rather than prevention in the construction of both HMOs and systems of health care delivery.
Like Matt, I think a key part of Longman’s argument is correct: Proactively healthy lifestyles would reduce insurance costs and keep patients healthier over the course of their lives. Everybody wins.
However, I don’t think Longman emphasizes enough how hard it is to generate healthy lifestyles. He suggests various incentives to get people to walk, eat healthy foods, and get preventative medical care, and while all these things do improve health, they don’t address one of the core problems with health lifestyles, namely that many issues we perceive as “lifestyle” are really about “life chances” (I’ve discussed this a little bit previously). Social scientists like Jo Phelan and Bruce Link and Catherine Ross and Chloe Bird have done a lot of work in this area, and they suggest that negative health outcomes of inequality (disparity in socioeconomic status, education, stress, for instance—- all of which are hard to change) persist despite changes in proximate causes of disease (such as diet and exercise).
What does this mean? Unfortunately, it means that well-intentioned programs that give incentives for people to choose healthy lifestyles are unlikely to address the underlying causes of illness. They may shift the location of disease, but won’t eradicate the disease, because many of the factors that determine health are simply beyond our ability to choose.
This isn’t to say that choice doesn’t matter: Ross and Bird, for instance, add weight to both life chances and life choices, by finding that, net of factors like stress and leisure time, men have a health advantage over women until the age of about 68 years. If men and women were equal in their consumption of healthy activities, this “crossover point” moves to about 54 years, according to Ross and Bird. What’s important about that age? Aside from shifting the balance by 14 years, it’s the time of early middle age, where quality of life is particularly important to many people.
What about choice? Well, choice comes partly into play because increasing smoking and obesity rates among women are slowly, but steadily, moving the crossover point back up into the 60s. Although there are plenty of arguments that situate diet and smoking in the “chances” category, these are reasonably something that might be affected by some of the recommendations made by Longman. Nonetheless, the insight of the social scientists persists: Health isn’t accounted for by individual action alone, and no amount of incentives for particular behaviors will address the persistent social causes of disease.
Health care is hard.