Resident Fellow Thomas P. Miller

Vulnerable populations are composed of vulnerable individuals. The temptation to sort the latter's diverse and complex health pathways into more familiar categories and boxes such as race and income proves irresistible for many researchers, policy advocates, and interest groups. However, when every relatively poorer health outcome "nail" looks like another opportunity to wield the group-based disparities "hammer," resulting policy approaches tend to lose sight of both the healthiest forests and the most promising trees and fail to make effective connections with either one.

This paper suggests some preliminary criteria and considerations for setting policy priorities. It recommends greater focus on early (but not prolonged) intervention, highlights the leveraged impact of improving individual decision making, cautions against underestimating the geographic underpinnings of health inequalities, and urges a more-balanced appreciation of absolute improvement.

How much? Perceived opportunities to find and address health disparities in vulnerable individuals and populations may appear limitless. The availability of resources and effective tools to alleviate, if not eliminate, them are not. Doing something, but not everything, and doing it better presumes an initial hierarchy of conditions measured along several scales that signal the degree to which more heightened levels and frequencies of intervention are advisable. For example, long-lasting and predictable conditions that may worsen over time involve higher stakes than acute, random ones of shorter durations, albeit costly ones. Persistence trumps concentration.[1] However, for permanent and disabling conditions, those related to less personally "controllable" factors elicit much greater sympathy and support than more "avoidable" ones. And conditions that are more "treatable" and potentially "reversible" make a stronger case based on higher returns on resource investments. Assessing "worthiness" for targeted interventions should occur at a level that balances the tractability of one's health condition with one's ability to command supportive resources. Such economic need (and opportunity) factors, however, should be evaluated at the individual level instead of being seen as a secondary consequence of one's group membership.

However, other considerations of political marketability may push public health interventions in different directions. Funding and popular support require identifiable constituencies that see some prospects of achieving visible "success" stories. Preventing or reducing unseen proclivities and susceptibilities to unhealthy conditions further downstream in time may lose out to the more immediately gratifying task of treating the conditions themselves and alleviating their obvious consequences. Helping more people a little may count for more than relieving the illness burden of a few a lot more. The political bias toward appearing to assist more constituents, instead of concentrating on those most vulnerable, is reflected in the original age-based entitlement criteria of Medicare social insurance, as well as rising income thresholds for recent Medicaid and State Children's Health Insurance Program (SCHIP) coverage expansions.

When? Interventions to improve the health of the vulnerable might be targeted at various stages of life or health conditions: starting points, midpoints, or endpoints. The U.S. system is clearly biased toward intervening with relatively expensive health care services during the last two stages--when the symptoms of poor health first become more acute, then chronic, and ultimately fatal. However, if one views these health services primarily as investments to reduce the rate of depreciation in the initial endowment of health over the life cycle, the important role of what Nobel laureate Robert Fogel terms that initial stock of "physiological capital" becomes more evident.[2] The shorthand summary of this important line of research is that long-term reductions in environmental hazards and chronic malnutrition have done more to reduce disparities in health status than has wider access to health care. Events early in the development stages of life, such as low birthweight, are linked to the later onset of chronic conditions The implications for intervention priorities are to focus much more on prenatal and early childhood care, encouragement of appropriate behavior by pregnant women, and reformation of destructive lifestyle practices that "are more frequently practiced among the poor and the poorly educated than among the rich and the well-educated."[3]

How? The physiological-capital strategy of early intervention also implies that improving outreach, mentoring, and education; and providing more convenient access to and better delivery of health services represents more important factors than expanding the level and scope of health insurance coverage per se. It still needs to be complemented and bolstered by a health-capital strategy that helps more vulnerable people effectively "produce" better health. One's initial health-capital stock may be increased or maintained by investment choices involving behavior (diet, exercise, cigarette smoking, and alcohol consumption) and, in particular, education level.[4] Education may change tastes or time preferences in a way that encourages future-oriented behavior and favors investments in health-promoting activities relative to other goods and services.[5] Along with social norms, these nonmedical factors account for much more of the variance in predicting health outcomes and producing disparities than differences in the use of health care itself or the financing of health insurance.[6]

Hence, a health-capital strategy aimed at improving health outcomes for more vulnerable people would focus on improving both their educational opportunities, deregulating the delivery and financing of medical services to provide patients with more choice and control, and increasing competition in health care markets. It also would expand counseling support to encourage more future-oriented behavior, offer more assistance for consumers navigating a complex health system, and improve access to more actionable consumer health information.

Where? The most recent examples of looking for health inequality causes in all the wrong places involve the "income inequality" hypothesis and the "biased doctor" model of treatment disparities.[7] The former presumes that reducing relative income inequality within large populations, rather than poverty levels per se, can improve overall health consequences. However, it suffers from ecological bias, overlooks the more important influence of income differences at the individual level, and neglects the diminishing returns of increased wealth (beyond median thresholds) on health improvement.[8]

The latter assumes that physicians give better care to their white patients than to their black patients solely on the basis of race. Subscribers to that hypothesis also tend to fixate on relative measures of health performance at the expense of absolute measures of improvement and gains for all, and they emphasize relative quantities of health services received rather than health outcomes achieved.[9] Its theory of causation generally confuses geographic health disparities in access to higher-quality physicians and health care systems with racial disparities.[10] The model also overlooks other critical patient-specific variables linked to treatment decisions and health outcomes, such as levels of personal autonomy, self-care, and unhealthy behavior.

Who decides? A fundamental starting point involves determining the primary locus of discretion and decision making. Instead of relying on surrogate "expert" decision makers to choose collective options aimed at prescribing illusory guarantees of specific outcomes, vulnerable people would be better served by more decentralized and pluralistic social processes that facilitate, but do not mandate, more effective choices. The latter establish rules and incentives that allow and encourage substantive trade-offs at the discretion of the many more scattered individuals who are most responsible for the immediate and long-term consequences. This constrained vision of causation makes a difference in differences, by aiming lower to hit higher and focusing on general effectiveness rather than achievement of individual results in isolation.[11]

Notes

1. In other words, it's not just "where the money is," but how long it stays in one place.

2. R.W. Fogel, "Secular Trends in Physiological Capital: Implications for Equity in Health Care," NBER Working Paper no. 9971 (Cambridge, Mass.: NBER, June 2003).

3. Ibid., 19.

4. See M. Grossman, "On the Concept of Health Capital and the Demand for Health," Journal of Political Economy 80, no. 2 (1972): 223-255; and B.D. Richman, "Behavioral Economics and Health Policy: Understanding Medicaid's Failure," Cornell Law Review 90, no. 3 (2005): 705-768.

5. M. Grossman, "The Human Capital Model," in Handbook of Health Economics 1A, ed. A.J. Culyer and J.P. Newhouse (Amsterdam: Elsevier, 2000), 397-404; see also M. Grossman and R. Kaestner, "Effects of Education on Health," in The Social Benefits of Education, ed. J.R. Behrman and N. Stacey (Ann Arbor: University of Michigan Press, 1997), 69-123. The effects of different education levels on several measures of health disparities is more mixed. See T. Miller, "Measuring Distributive Injustice on a Different Scale," Law and Contemporary Problems 69, no. 4 (2006): 233-235.

6. Miller, "Measuring Distributive Injustice," 232.

7. N. Eberstadt and S. Satel, Health and the Income Inequality Hypothesis: A Doctrine in Search of Data (Washington: AEI Press, 2004); and J. Klick and S. Satel, The Health Disparities Myth: Diagnosing the Treatment Gap (Washington: AEI Press, 2006).

8. Eberstadt and Satel, Health and the Income Inequality Hypothesis.

9. Klick and Satel, The Health Disparities Myth, 5-6; see also D. Mechanic, "Policy Challenges in Addressing Racial Disparities and Improving Population Health," Health Affairs 24, no. 2 (2005): 336; and S. Satel and J. Klick, "Are Doctors Biased? The Factors Underlying Disparities in Treatment," Policy Review, no. 136 (2006): 41-54.

10. Given current geographic variation in practice styles, access to specialized services, and hospital quality, "where" one is treated often determines "how" effectively one is treated once there.

11. See T. Sowell, A Conflict of Visions: Ideological Origins of Political Struggles (New York: William Morrow and Company, 1987).