Carmen Mitchell is currently a fourth-year health policy doctoral student in the Department of Health Management and Systems Sciences at the University of Louisville School of Public Health and Information Sciences (SPHIS). She is currently affiliated with The Afya Project, an interdisciplinary research initiative seeking to increase PrEP availability and use among African Americans in Louisville, Kentucky. She completed her Master’s in public health in 2016 at the University of Louisville. She tweets at @carmenrmitchell.
In Christmas Eve tweets, the entrepreneur and presidential candidate Andrew Yang expressed the following:
Our healthcare expenses of $3.6 trillion are almost $12,000 per person per year. A couple thousand dollars a year to ‘spend’ on things that make us healthier would go a very long way.
— Andrew Yang🧢⬆️🇺🇸 (@AndrewYang) December 24, 2019
Yang’s tweets were widely interpreted to mean if more people ate healthier and exercised more, healthcare expenses would be lower and population health outcomes better. Though intuitive to many, healthcare is not this simple.
Let’s start with the relationship between health-related behaviors (like diet and exercise) and spending. Unfortunately, as Dr. Aaron Carroll notes in the New York Times, the research on different types of preventative care — including interventions centered on health behavior —consistently fails to find savings.
Of course, just because there isn’t an immediate payoff from healthy behaviors doesn’t mean that we shouldn’t encourage them. But, in doing so, we should be honest about the benefits: eating well and exercising regularly are good for health and wellbeing.
Even so, they won’t address some of America’s major health problems. Granted, heart disease — which is associated with diet and exercise — remains the top cause of death in the United States.
But suicide and drug overdose — which are not associated with diet and exercise — remain top killers for adults in the U.S. between the ages of 15 and 64. As recently as 2017, homicide was ranked 4th for causes of death among Black men (and #1 overall among Black men under 45), while HIV and complications related to pregnancy are among the top 10 causes of death for Black women between ages 20 and 44. Neither gym memberships nor healthy eating habits would fix any of this.
Furthermore, using financial incentives to promote diet and exercise (as Yang is suggesting) misses the underlying structural factors driving health behaviors. For example, food intake behaviors are influenced by many community and structural factors, including prices, accessibility, social and cultural norms, and habits developed during formative years. Those can’t be fixed by sending people to nutritionists. The same goes for exercise and buying gym memberships.
Calling for better diets and more exercise as solutions, even if they worked, has classist and racist undertones. People who have low-incomes will not have the resources to purchase the food a nutritionist would recommend, and they may not have the time to go to the gym if they are balancing multiple jobs and families. People of color disproportionately face these structural barriers.
This isn’t a fine point. Yang’s suggestions miss a lot of people and a lot of deep problems. A recent report estimated that nearly 44% of the US workforce — 53 million people — work in “low wage” jobs. Most of these workers lack college degrees and are women and/or people of color.
As has been written about extensively, Black Americans are more likely to experience chronic financial instability as a result of racist policies, and the corresponding community problems that arise from it. They are more likely to live in environmentally polluted neighborhoods (think Flint, MI, although this is a phenomenon everywhere), experience incarceration, and have fractured relationships with healthcare services because of completely justifiable medical mistrust, as well as suffer from constant stress of racism and racism-based encounters.
All of these are major drivers of health that cannot be fixed with diet and exercise. They are longstanding American problems that today’s candidates and elected officials, including Yang, rarely address head on.
To those of us who work in health services research, I likely haven’t mentioned anything you don’t know; we are very aware that tackling continuously rising spending and working to address health outcomes will require a significant amount of structural reform outside the health system and beyond the individual.
Despite this, the language of individualism and personal responsibility pervades talking points among public officials. They’re correct that to improve health for all Americans we need to look beyond the health system. But they’re wrong to think we don’t need to look within other complex social, cultural, economic, and political systems.
For example, in the halls of the state capitol in my home state of Kentucky, one of the states hit hardest by the opioid crisis, it is still quite common to hear public officials point to individuals’ moral failings as the problem’s source and their personal responsibility as the solution. In truth, failure in government oversight and economic distress have both played large roles in the problem. We won’t be able to meaningfully tackle it without addressing those systematic factors, along with promoting evidence-based medical treatment in lieu of shame and punishment.
Individual-centered messaging would be less of a problem if it was just coming from Yang and a small group of like-minded policymakers. Unfortunately, we hear similar messages from many facets of society, including “health and wellness” media and advertising (both for-profit and non-profit), workplaces, doctors and other healthcare professionals, public health institutions and health-focused academic disciplines.
This partially reflects a failure of the health services research disciplines to effectively communicate the truths we’ve learned. What else can we do?
As I have argued previously, incorporating more systems-focused curriculum in graduate training would be a great way to help future health researchers and practitioners move away from individual centered-thinking. We might also promote more opportunities to build translation and communication skills among health professionals; there are currently several AcademyHealth initiatives for this purpose, though we might consider how we can create more accessible learning on campus. (As an example, this week Cornell announced a new undergraduate minor in science communication.)
We could also seek more ways to partner with organizations focused on improving community health in a systematic way. Drivers of Health, a Robert Wood Johnson funded project examining meaningful empirical research on social determinants, is a great example of this.
If we — policymakers and health services researchers alike — are all committed to improving population health, it is imperative that we shift the conversation to the true underlying causes. We have a lot of work to do. Flint Michigan still doesn’t have clean water. Nearly 3 in 10 Americans skip filling a prescription because of costs. So, let’s focus less on gym memberships and more on what really matters.