The Headwaters

The Healthcode System  ...  Chapter 9

The previous chapter aimed the codes at health, then admitted how far that aim could carry: as far as a clinician's panel can reach, and no farther. This chapter is about everything past that range, which turns out to be most of what keeps a person well.

There is an old parable about a village beside a river. People keep washing downstream, drowning, and the villagers grow expert at pulling them out  ...  better nets, faster boats, a whole heroic apparatus of rescue. No one walks upstream to ask why so many keep falling in. American medicine is that village, and it has built the finest rescue operation in the history of the world at the exact point where people are already in the water. The question this chapter asks is why we send almost nothing to the headwaters.

The case for the headwaters is not sentimental; it is measured. When researchers weigh what actually determines a population's length and quality of life, medical care accounts for only about a fifth of the result.[1] The largest share, roughly forty percent, belongs to social and economic conditions: income, education, employment, the safety of a street. Another thirty percent tracks behavior, and ten percent the physical environment.[1] The physician, custodian of the most expensive lever, commands the shortest one... Four-fifths of what makes us well is decided before anyone reaches an exam room.

We have arranged our spending in near-perfect opposition to that fact. The United States pays more for medical care than any nation on earth, close to a fifth of its entire economy; yet when medical and social spending are summed together, it sits near the middle of its peers, with middling outcomes to match.[2] The reason is the ratio. The country holds the lowest proportion of social-to-medical spending in the developed world  ...  where comparable nations spend roughly two dollars on social supports for every medical dollar, the United States spends about one.[2] That ratio predicts health: nations and states that lean toward social spending post better outcomes, a relationship that holds even when the United States is dropped from the data.[3] Meanwhile public health and prevention, the work aimed directly at the headwaters, receives roughly three cents of every health dollar, a share that has fallen for two decades.[4] We built a five-trillion-dollar rescue and starved the work that would keep people out of the river.

No payment model reaches the headwaters, and the previous chapter's cannot either. At its best it pays for the population that never needed the stent  ...  real, and still downstream. The determinants live beyond every payment model for reasons that are finally one reason. They belong to no provider's panel: a landlord, a school board, an employer, a zoning commission shape them, and none of them bills Medicare. They ripen across decades, the lead paint scraped from a child's wall paying its dividend forty years on, in a body the original payer will never meet. They span sectors that do not answer to the health system at all. They resist attribution by their very nature  ...  which is the same reason the code was always blind to them, because their product is the negative space of the sixth chapter, the crisis that never arrived, spread thin across a whole neighborhood and a whole life. No claim, no panel, no annual cycle can hold a thing like that.

The reflex of a system made of codes is to meet this with more codes. There is already a movement to give social needs their own diagnostic codes, to have hospitals screen for hunger and housing and bill for the screening, to medicalize the determinants so the apparatus can finally see them. The instinct is generous and the error is precisely the one this series has followed from its first page. To code housing as a health intervention is to subordinate the home to the logic of the claim  ...  to make shelter legible only as a line item, fundable only once a clinician has documented a patient's need, governed again by the machinery whose blindness created the problem. The headwaters cannot be saved by being poured into the code. They have to be funded and governed on their own terms, which is to say outside the health-code system altogether.

What that outside looks like has a shape, and the shape is not medicine's. It rests on three supports. The first is dedicated public health funding  ...  a stream that does not run through the claims system and does not compete, dollar against dollar, with the next imaging suite; sustained rather than surged in a crisis and abandoned after it; aimed at conditions instead of encounters. The second is community-led power, because the determinants are local and lived, and the people inside a place, not a distant payer, are the ones who can say what its health requires. Prevention done to a community tends to fail where prevention directed by one tends to hold. The third is cross-sector accountability, because health is manufactured in housing and schools and workplaces and air, and the responsibility for it must span those sectors rather than sit orphaned inside a starved health department  ...  health counted as a result of housing policy, education policy, labor and environmental policy, and not quarantined as the private business of medicine.

Honesty requires admitting this is the harder of the two reforms, because pretending otherwise would repeat exactly the overselling the seventh chapter warned against. It is harder politically: the headwaters have no lobby the size of the medical industry, no charge that posts automatically, no constituency organized around a billing code. It is harder to measure: the returns are diffuse, delayed, and stubborn to attribute, and the very qualities that keep them off the claim form keep them off the budget in a country that asks each dollar to prove itself by next quarter. The returns are real all the same  ...  the spending-ratio studies are not subtle, and well-built community programs can return many dollars for each one spent. The fair comparison was never against perfection. It is against the status quo, which is the most expensive failure available: a five-trillion-dollar machine, outgrowing the economy that feeds it, buying outcomes its peers reach for half the price.

The argument now stands at its full height, and it has two hands. With one, aim the codes at health, so that the majority of medicine's money rewards the patient who got well rather than the procedure performed. With the other, build  ...  outside the codes, on its own terms  ...  the public health and social infrastructure that produces health long before a patient is ever made. One reform turns the apparatus toward the right target. The other funds the work the apparatus was never able to see. Neither alone is enough: the first without the second is a sick-care system with better aim; the second without the first leaves the old machine standing to swallow the savings. Together, they would amount at last to the thing this country keeps claiming to possess and has never once built.

What that thing should be called, and what it would ask of us to mean the word honestly, is the subject of the last word that follows.

Notes

1. The County Health Rankings model weights modifiable determinants of health as approximately 40% social and economic factors, 30% health behaviors, 20% clinical care, and 10% physical environment; an empirical validation of the model placed clinical care's contribution near 16%. University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation, County Health Rankings model; Hood, Gennuso, Swain & Catlin, "County Health Rankings: Relationships Between Determinant Factors and Health Outcomes," American Journal of Preventive Medicine (2016).

2. The U.S. spends more on medical care than any nation (about 18% of GDP) but ranks near the OECD average once medical and social-service spending are summed; it has the lowest ratio of social-service to health-care spending in the OECD, where peer nations spend roughly two dollars on social services for each medical dollar and the U.S. spends about one. Elizabeth H. Bradley and Lauren A. Taylor, The American Health Care Paradox (2013); Bradley, Sipsma & Taylor, QJM (2017).

3. The ratio of social-service to health-care spending is significantly associated with better health outcomes across OECD countries and across U.S. states  ...  a relationship that held even when the United States was excluded from the analysis. Bradley et al., Health Affairs (2011 and 2016); Robert Wood Johnson Foundation.

Government public health and prevention account for roughly 3% of U.S. health spending (about 3.3%, or $160 billion, in 2023; preventive care about 2.9% in 2018), a share that has declined since roughly 2002. Trust for America's Health, "The Impact of Chronic Underfunding on America's Public Health System" (2020); Bishai, Leider & Resnick, "Public Health's Falling Share of US Health Spending," American Journal of Public Health (2016); CMS National Health Expenditure Accounts.