woman stretching outside

We invite readers to respond to a call for papers that has recently been issued from the journal Health Services Research. The call invites papers that present new research on the key questions of factors that affect broad measures of the health of populations.

Why This Topic? Why Now?

It is a commonplace observation to note that (a) the United States spends more on health care than any other country; and (b) Americans are not healthier, on average, than people in many other developed countries. The conclusion from those two points is that we’re spending our health care dollars inefficiently, as the “outcomes” (broad measures of health status like mortality) aren’t commensurate with the level of spending.

This line of thinking, and even the words used like “outcomes” of health care spending reflect a vision of health that links it very closely to health care as an “outcome”. But, is overall health at the population level really a product of health care or an outcome of health care?

To some extent, and for many individuals, it clearly is. Medical care saves lives in many injuries or accidents, and can also restore or preserve function for people, so that their being alive and healthy and able to live normal lives is a function of the health care that they’ve received. It’s also true that people who have access to health care through having insurance, and people who have a regular source of primary care, tend to be healthier on a variety of metrics and are likely to live longer.

But, when we examine broad population health statistics, and particularly when we compare countries to each other on measures of health like mortality or functional status, are we seeing the effects of health care, or are we seeing the effects of other factors like lifestyle (diet and exercise), government spending on social services that can affect health in the long run (housing, education, day care for young children), healthy environment, social cohesion or social support, or genetic factors?

All of these other factors have been shown to matter, and the relationships between socioeconomic variables like income and education and health have been known for decades, if not even longer. When we compare levels of health among countries, it’s clearly important to take into account the effects of factors other than health care before we draw conclusions about the value of our high levels of health care spending.

Understanding the effects of a range of factors like these is made particularly difficult because the causal effects are neither always direct nor always linear. People with higher incomes in white-collar jobs can be healthier because they are more able to pay for things that improve or maintain health. On the other hand, healthier individuals are better able to work long hours and be productive when at work, so are more likely to rise to higher-level, better-paid jobs. The causal arrows run in both directions.

In this relationship, income may not even be the true key factor. Income is correlated with education, and maybe education is the factor that really matters. Level of education in turn is correlated with individual factors like cognitive ability and ability to be organized and diligent in completing assigned tasks, and with family or social factors like parents’ education or expectations about educational achievement and achievement in general in the community. Maybe those are the factors that truly affect health, with both income and education as proxies or markers for what really matters.

These are not new questions or issues for study. There is a rich literature on these topics, with conclusions occasionally expressed in percentage terms — an example would be a conclusion that population health is only 10% due to health care and 90% due to other factors like lifestyle, SES, genetics, and community-level factors like pollution, crime levels, or availability of exercise opportunities. (There are a number of problems with conclusions of this type, which are beyond the scope of this post.)

A New Initiative on “What Drives Health”

With funding from the Robert Wood Johnson Foundation, a group of researchers has committed itself to a one-year review of literature on the topic of “What Drives Health”, and finding any new information that would help our understanding of how the mix of personal, social, and health care factors ultimately contribute to measures of population health.

The project is led by one of us (Austin Frakt) and the other (David Nerenz) serves on an advisory committee, co-chaired by fellow AcademyHealth members, Sherry Glied of NYU and Ashish Jha of Harvard. The committee and project staff are working together through a set of in-person meetings and conference calls to sift through the currently-available academic literature as well as information provided through presentations by public health experts, community leaders, health care providers, and others with unique perspectives on the key question of “what drives health”. (Further details about the project and meetings here.)

As part of this process, the call for papers invites manuscripts that present new research on the key questions of drivers of health. Selected papers will appear in a special issue of HSR in June of 2020, and will inform the work of the committee as it prepares its own report on drivers of health for release in 2020.

This work is not simply an academic exercise. Important questions about priorities for government programs or funding are based on knowledge of how best to improve population health. Similarly, major employers who have an interest in the health of their employee population, and health plans or ACOs that have a stake in the health status of their long-term members, must constantly make decisions about how much to spend on medical care vs. how much might be spent on other things that might improve health (and perhaps reduce medical care spending in the long run).

Foundations like the Robert Wood Johnson who care about broad improvements in population health must similarly make priority decisions for their funding and programming. A clearer understanding of the drivers of health, and the complex causal pathways through which those drivers exert their influence, will help us all make better decisions about how to invest in things that improve health.

David R. Nerenz
Member, Presenter

David R. Nerenz, Ph.D.

Director Emeritus - Center for Health Policy and Health Services Research

David R. Nerenz, Ph.D., is Director Emeritus, Center for Health Policy and Health Services Research, Vice-Chai... Read Bio

Austin Frakt
Author, Committee Member, Member

Austin Frakt, Ph.D.

Director and Associate Professor - Partnered Evidence-Based Policy Resource Center

Austin is a health economist, associate professor, and researcher; the creator, co-manager, and a primary auth... Read Bio

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