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March 2015 (Volume 93)
David A. Kindig
One of the most critical issues facing us today is finding a political and ideological common ground for improving population health. For nearly 50 years I’ve worked in this policy area, looking at national and state maps that show seemingly unchanging and intractable disparities by geography, race, and socioeconomic status. While absolute levels of many outcomes have improved during this time, relative gaps persist and remain unacceptable.
I refuse to join, however, with many people on both the left and the right of the political spectrum who claim that the same ideological differences that poison our efforts on hot-button issues like abortion and mainstream issues like managing the economy also must block efforts to improve population health. For example, we seem to have become increasingly unified around the basic goal that our children live as long and with the same quality as their counterparts in other developed countries. Sadly, we have not reached the point that we have matched or exceeded the success of these other nations.1
Many public and population health experts tend to approach this issue of common ground through a lens of social justice and principles of fairness. But many of our unhealthier communities are in more politically conservative areas of the nation, whose inhabitants have different assumptions about how social programs and population health have affected local, state, and national policy for more than a century. Thus the improvement that many of us seek will not progress without substantial efforts from the citizens and policymakers in these areas. Are there additional value frameworks for these common goals that might make possible the creation of a coalition for improving population health beyond the relatively small public health community?
I have been influenced in my thinking by the work of the moral psychologist Jonathan Haidt.2 His extensive survey research reveals that while both liberals and conservatives share values like caring, liberty, and fairness, conservatives also tend to embrace others like loyalty, authority, and sanctity. While Haidt’s dichotomy may be overly simplistic because it does not account sufficiently for the many individual differences and for changes in ideology over time, it helps to explain much about the current ideological and policymaking gridlock.
One major ideological difference in population health policy is the role of individual responsibility in producing and maintaining health. Although each of us must take personal responsibility for many of our health choices, we also know that making healthy choices is much harder for people with less education and/or fewer economic or social resources. Population health science tells us that health is produced by many determinants, including health care and health behaviors, as well as by social and environmental factors. The widely recognized County Health Rankings model gives 50% weight to these latter determinants (www.countyhealthrankings.org/our-approach). For example, we now know that education is as important as clinical care in making us healthier, but for many states and communities, the per capita investment in all areas of education, including early childhood, is far behind that of the country’s healthier areas. Action by community organizations and government is needed, beyond individual responsibility, to improve schools, promote economic development, and ensure affordable access to care so that we all can live longer and more productive lives.
One common-ground political approach to making communities healthier might be to apply those values that conservatives also consider important. An example of this is the recent study by the population health researchers Sarah E. Gollust, Jeff Niederdeppe, and Colleen L. Barry, which examined the effects of messages describing the consequences of public attitudes toward government action to prevent obesity.3 Messages about health care costs and bullying in schools motivated both liberals and moderates. But messages highlighting the negative impact of obesity on military readiness substantially increased the conservatives’ perceptions of the seriousness of the issue, and this may encourage conservative public policymakers to join forces with progressive or liberal policymakers on the obesity issue.
Other aspects of being healthy might also appeal to broader value sets such as workforce productivity. There is considerable evidence that unhealthy workers detract from a company’s bottom line through higher health care costs and reduced work efficiency. Some companies have even based their decisions about plant locations on health costs or health indicators. Other research has also demonstrated that the likelihood of family disruption increases when children suffer poor physical and mental health. If such evidence is compelling across the political spectrum, a major challenge for the politics of population health policy will be to communicate this effectively. Such communication needs to emphasize that much of health improvement requires a broad portfolio of strategies in the private and public sectors, particularly on social determinants like education, jobs, and economic development.
Haidt’s research also demonstrates an important nuance between liberals’ and conservatives’ values. While both sides of the aisle agree on the fairness moral frame, Haidt found that liberals tend to view fairness as equality of outcome and conservatives are more likely to see it from a perspective of equality of opportunity. Yet much research and advocacy in population health has focused on achieving equality of outcomes by reducing racial and socioeconomic disparities. For example, the County Health Rankings defines such outcomes (ie, lower mortality, less disease) as goals, but it also ranks counties on various factors like health care, health behaviors, and the social and physical environment. Although these latter factors influence health outcomes, they are not the outcomes themselves.
Could recognizing and building upon different moral views of fairness create common ground for improving health? Might conservatives embrace governmental action that seeks to improve health determinants as opportunities rather than explicitly supporting equal outcomes themselves? As the Nobel Laureate and economist Amartya Sen noted, “A major reason we don’t reduce disparities is the different ideological treatment of outcome.” The Centers for Disease Control and Prevention defines health equity as “when all people have the opportunity to attain their full health potential.”
While keeping overall health outcomes in mind, could we all embrace opportunity policies like education and economic development, which produce health along with other benefits? Nobel Laureate and economist James Heckman observed that “it is a rare public policy initiative that promotes fairness and social justice and, at the same time, promotes productivity in the economy and in society at large. Investing in disadvantaged young children is such a policy.”4 Many business leaders realize this and acknowledge the importance of such a policy for current and future workforce productivity and for their company’s profitability. To improve health, how can we identify and promote more inclusive moral frameworks and imperatives that incentivize military readiness, economic productivity, and marriage stability? It would be unrealistic to think that we will ever have complete equality of health or shared values, but is there a compelling reason that we can’t build coalitions among persons who embrace competing ideologies to accelerate community well-being and national economic security?
Whether you are inclined to reply affirmatively or negatively, red or blue, right or left to that query, the reality is that our nation simply cannot accept yes as an answer.
Author(s): David A. Kindig
Read on Wiley Online Library
Volume 93, Issue 1 (pages 24–27)
Published in 2015
David A. Kindig, MD, PhD, is emeritus professor of population health sciences and emeritus vice-chancellor for health sciences at the University of Wisconsin–Madison School of Medicine. He currently is cochair of the Institute of Medicine Roundtable on Population Health Improvement and codirects the Wisconsin site of the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars Program. He was an initial co-principal investigator on the RWJF MATCH grant under which the County Health Rankings were developed and was the founder of the RWJF Roadmaps to Health Prize. He received a BA from Carleton College and MD and PhD degrees from the University of Chicago School of Medicine.
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