Health & Medicine

What’s the biggest driver of health care costs? Our personal behaviors.

Steve Shortell

The recently passed Affordable Care Act extends health insurance coverage to 32 million Americans, including at least 6 million people in California alone. But expanding access to health care will do little to improve our health.

Fifty percent of the determinants of health are due to our behaviors; 20 percent to environmental factors; 20 percent to genetics; and only 10 percent to having access to medical care. Yet in California and as a nation we spend 96 percent of health expenditures on medical services and only 4 percent on preventing disease and promoting health.

The majority of the most costly health conditions are preventable, including obesity, diabetes, heart disease and asthma. Physical inactivity and obesity cost the state $388 million per year in workers’ compensation and $11.2 billion in lost productivity.

Fifty-six percent of California adults and 30 percent of our children are overweight or obese. The total economic impact of asthma in the state is $14 billion, including 14 million lost school days and 14.5 million lost workdays. Even a modest 5 percent reduction in these and related illnesses could save the state up to $1.6 billion a year.

Interventions are needed that recognize the interaction between our personal behaviors – diet, exercise, lifestyle – and the communities in which we live.

Taking personal responsibility for our health is important. But we can make healthy choices only if there are healthy options to choose from. We need to ensure that the decisions we make about our community are those that promote healthy living; that make it easier for us to do things that promote our health and well-being and difficult to do things that are harmful.

This means access to clean air, safe water, fresh fruits and vegetables, environmentally safe buildings, parks, recreation, roads, and education and cultural opportunities. This is the philosophy of “health in all” policies in which the goal of reducing illness and injury is embedded in cooperative efforts that link our public health and medical institutions with our education, agriculture, housing, transportation and related sectors.

For example, if we design housing with access to trees, parks and recreational facilities, residents are more likely to engage in physical activity and less likely to suffer from heat-related illnesses in extreme weather than if we have housing designed or located without such features. Building attractive and green housing has health benefits.

The health care reform legislation offers some opportunity to enact “health in all” policies. A Prevention and Public Health fund is created along with a Federal Preventive Services Task Force and a Public Health Council. Ten billion dollars will be allocated over the next five years for prevention programs. This includes a “Creating Healthier Communities” grant program for health departments to implement various prevention initiatives to reduce chronic diseases and eliminate inequalities in health by race, ethnicity and socioeconomic status.

But California, and many other states, will be challenged to respond to this opportunity due to a severe shortage of trained public health professionals, inadequate data systems and the need for performance standards.

To seize the opportunity to invest in health and reduce the economic burden of disease on the state will require creative leadership on the part of both public officials and the private sector. Concerted efforts to provide the leadership and resources to address the underlying behavioral, social and environmental determinants of health will have a greater impact on our health status and economy than any of the health care delivery system efforts to cope with the expanded access to care afforded by the increase in health insurance coverage.

Cross-posted from The Sacramento Bee.

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Comments to "What’s the biggest driver of health care costs? Our personal behaviors.":
    • Thomas Leo Ogren

      “The total economic impact of asthma in the state is $14 billion, including 14 million lost school days and 14.5 million lost workdays. Even a modest 5 percent reduction in these and related illnesses could save the state up to $1.6 billion a year.

      Interventions are needed that recognize the interaction between our personal behaviors – diet, exercise, lifestyle – and the communities in which we live.”

      The above is all true enough, and it doesn’t take into account the vast amount of money wasted on allergies. There is one very simple, win-win way in which any city could reduce their costs on both asthma and allergies…and that is to implement the concepts of Allergy-Free Gardening. Pollen is the most common allergic trigger. The great majority of those with asthma also have allergies to pollen. Having pollen-allergies also increases one’s risk of developing asthma.

      The State of California did write Allergy-free Gardening principles into its Strategic Plan for Asthma (two years ago)…but they have done nothing at all to implement it. The UC School of Public Health doesn’t teach a single class on it, far as I know.

      Bottom line is it makes no sense whatsoever to keep on planting highly allergenic trees and shrubs near where people live, work, shop, or go to school…but all across the US this is exactly what is still being done.

      For almost every high allergy shrub or tree sold, there is an equally attractive and useful low-pollen or pollen-free alternative…yet these are almost never used. For the many millions with asthma or allergies, they can allergy-free their own yards, and it’s a great idea…but to do this right, the cities need to start doing it…and the universities, especially those focused on Public Health…they need to step up to the plate and take the lead.

      Personal behaviors – diet, exercise, lifestyle…none of these will solve this amazingly huge problem….here we need some leadership from those in Public Health. Interventions are needed indeed!

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    • paul

      I think the biggest driver for the health care cost are for citizens to have correct attitude toward their own health.

      Firstly people should start changing their eating hobbit on the high calories foods and sugar drinks. By building the correct eating hobbit is maybe the most important thing the government should educate the people especially young children on the influence of major decease caused by the improper eating hobbit. Less salt, less oil, and less sugar drink.

      Paul Lu

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    • Brian

      Diet is just an important part of the puzzle as all the rest. Correct use of food should be taught early on in schools, whereas most schools seem to be vendors of junk food and sugar (mainly in soda’s. Obesity is preventable, but it needs to be addressed in the correct manner, and that is a proper and unbiased look at the modern diet. There are too many vested interests with huge budgets and a hidden agenda at this point to have a totally unbiased view. Why do University research teams come up with sensible answers, that are then totally ignored because of all the vested interested companies.

      Health, and truth, should be put before money. And if, for instance, it can be proved that a certain crop or grain or dairy or whatever causes obesity, then that sector should not be offered the protection of the powers that be just so they can keep making money on others demise of health.

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    • Ellen Simms

      It’s not my behavior that produces heavy woodsmoke in my North Berkeley neighborhood, which sets off my asthma. Many of your examples are not “personal” behaviors. They result from societal decisions that individuals often have very little ability to influence. Still, I think it’s very important to recognize that, except perhaps in the very elderly, environment is far more important than are genes in determining the general health of individuals.

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    • Frank Roseman

      The lack of free market absolutely prevents both advancement as well as reach for those who can’t really get it, in a way it created some sort of monopolistic approach and is an ironic slap in the face to the Hippocratic Oath that medical personnel take.

      Money should not drive the quality of the service, rather equality for all. or at least try to make it.
      it’s not a perfect system and there are flaws in every social health system such as Canada, France… but at least it’s a good and equal base to start building on.

      Frank Roseman

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    • Jerry

      Dean Shortell,
      You mention in your article,”to seize the opportunity to invest in health and reduce the economic burden of disease on the state will require creative leadership on the part of both public officials and the private sector.”
      I belong to the private sector and have some ideas. Who would you suggest I contact to discuss further.
      cheers,Jerry

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    • KetoSiska

      Just wanted to add something related to what Gary Lehrer said above. It may be hard to start and get used to ketogenic diet, but at the end, most of the people eventually see the benefits of this diet. I know many people who successfully applied this diet in conditions like epilepsy, but some also find it effective in weight loss.

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    • Dale Michaels

      The preventable diseases that obesity causes are so well documented and are in the news so often (daily) that there really is no excuse for any individual to be unaware of the serious health issue that overweight and obesity has become.

      The only way that this huge health problem will change for the better is when you and me as individuals make a conscious decision to change our lifestyles. An effective weight loss program will work, but only when one makes a commitment to following one.

      Just as Americans and Canadians have become lazy financially; that is most people take no care of themselves financially; most people have also become physically lazy.

      There’s not shortcut to maintaining a healthy weight. Only regular exercise and good eating can accomplish it.

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    • Ann Salzer

      I agree the lack of free-market principles has some influence on the healthcare costs. Actually the New York Times published a study in 2007 that showed how healthcare costs raised faster than inflation and Dental care raised faster than the healthcare category. So economic rules seem not to apply.

      But I think in good part os due to the lack of public interest in the topic. For sure we all want lower costs, but we refuse to devote time to participate in solving the problem. Last week I found about yet another company trying to address part of the problem: http://www.mebik.org, a seattle based movement that offers access to cost info. They launched last week, they have like 30 friends on Facebook. Celebrities gossip sites have millions of followers, yet sites like http://www.mebik.org or http://www.realself.com have few users comparatively speaking. And the media perpetuates the problem by giving coverage to gossip, politics and bizarre things rather than offering access to solutions that at least can help us to make better decisions.

      So I wonder if the answer is regulation, because the average american is just too lazy to care. Note I disagree that insurance plans are the problem, because even for dental, where as per mebik.org 40% of the expenses are out-of-pocket, people seem not to care.

      Active participation and realizing if people want to “bother” to be active participants is yet another angle to evaluate when looking at the healthcare puzzle.

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    • Greg Gombar

      Dear Dean Shortell

      Can you provide the source of your study, data etc

      Fifty percent of the determinants of health are due to our behaviors; 20 percent to environmental factors; 20 percent to genetics; and only 10 percent to having access to medical care. Yet in California and as a nation we spend 96 percent of health expenditures on medical services and only 4 percent on preventing disease and promoting

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    • George white

      The biggest cause of health care costs today is lack of free market principles in the health care system, mandates for employer paid health insurance, bureaucracies formed to administer health care and Obamacare itself. Your points are well taken, though.

      My clinical ecologist was a pioneer in the health care industry, he emphasized diet and eating healthy and felt that there was a conspiracy of medical schools and pharmaceutical companies to make sure that we used drugs and standard medical procedures as opposed to more natural and non invasive healing techniques.

      Thanks
      George White

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    • Jo

      Here are some decent facts. Intelligent design or scientific evolution created our body’s cells to accept certain molecules, which of course come from our consumption for energy. When genetically manipulating foodstuff, as happened for 60 years the cell does not recognize it and the cell receptors reject these modified molecule chains. So our kids need to eat more to get the same energy as a smaller portion of what God made for our consumption. But the leftist in Academia are monetarily wed to to the Phrama-Vitamin global corporations that fund academia to claim the GMO do not cause cancer. our body makes 800,000,000 cells a day, mitosis, remember? And so if our body is rejecting GMO molecules, we can cause a disruption of natural biochemistry — causing overweight, and causing cancer. You can cure cancer yourself by ingesting raw foods not modified by human scientists. This GMO creates sick people which raise costs in healthcare. But this is persuasive argument, the type of rhetory of the founding fathers. Today, this no longer exists, it is sound-bytes like It’s all Booooooshhheeee’s fault as the culmination of rational [actually irrational] nonsense. Finally, the poor cannot buy whole foods, which is a conspiricy like nothing else.

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    • Gary Lehrer ('77)

      Jo, I think the biggest cause of health care costs today is lack of free market principles in the health care system, mandates for employer paid health insurance, bureaucracies formed to administer health care and Obamacare itself. Your points are well taken, though. My clinical ecologist was a pioneer in the health care industry, he emphasized diet and eating healthy and felt that there was a conspiracy of medical schools and pharmaceutical companies to make sure that we used drugs and standard medical procedures as opposed to more natural and non invasive healing techniques. As a matter we just saw a great movie with Meryl Streep (First Do No Harm) about how the ketogenic diet originated at Johns Hopkins is used to treat epilepsy. Jo, overall, you make too much sense. Did you actually go to Berkeley?

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    • Ella

      It would be nice to see if the Federal Preventive Services Task Force and the Public Health Council use some of the ‘Prevention and Public Health Fund’ to monitor our food supply.

      Yes, we can and should limit pre-processed foods that are loaded with fat, salt, and extra carbohydrates, but how do we combat adulterated food when some ‘growers’ use fields contaminated with harmful pesticides, chemical fertilizers and put hormones in our milk and meat?

      ‘growers not farmers’

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    • Bronwen Rowlands

      Dear Dean Shortell,

      Re these 32 million Americans who will be newly covered under the health reform act: I have never seen any detailed information about how this will work. As dean of the UCB School of Public Health, you will likely know. Can you direct me to it? Thank you.

      An observation: As a lower-income UC employee, I can only say that my health care costs have increased since the passage of the so-called Affordable Care Act. My health status has not changed; the increase is due solely to increases in the cost of medication and other health insurance costs. And, as you know, there will be a dramatic increase in the cost of UC health benefits beginning in January. (Please don’t counter with assurances re the new “Blue & Gold” HealthNet HMO; it seems to have been created so that the Alta Bates Medical Group could be deleted from the coverage. A better name would be “Blood and Rust.”)

      Finally, your breakdown of the “determinants of health” are misleading. “Only 10 percent to having access to medical care” is surely true only for a relatively wealthy population.

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