Morgan T. Sammons, PhD, ABPP
Writing this column so soon after the 4th of July, a theme of independence seemed natural to pursue. It is good to reflect on what our democracy has brought us over the past 250 years. With the release of this column coinciding with dramatic events in the healthcare debate going on in Congress, it is also good to reflect what the future may hold, and the role that we as psychologists can play, along with other healthcare providers, in shaping that future.
It is my belief that we should view investments in healthcare as an investment in the future of our citizenry. That belief is well supported by evidence, both confirmatory and contradictory. On the confirmatory side we have studies that clearly demonstrate a link between health-related social spending and reductions in all cause morbidity and mortality. Investing in programs like school and afterschool programs, job training, and other aspects associated with healthcare results in an increase in life expectancy and an overall lowering of healthcare costs. For an extremely compelling, if somewhat depressing, demographic showing how the U.S. lags behind other industrialized nations in terms of life expectancy despite our extremely costly healthcare system, see the graph accompanying Robbie Gramer’s article in the March Foreign Affairs (http://foreignpolicy.com/2017/03/24/infographic-u-s-health-care-compared-to-the-rest-of-the-world-not-pretty). In both Europe and Asia, countries that invest in health-related programs and focus less on health expenditures have life expectancies that only the most privileged Americans can anticipate.
On the contradictory side, evidence is bleak and compelling. A new study in JAMA: Internal Medicine demonstrates a very clear pattern linking the geography of poverty with declines in lifespan in America—and these declines are significant. Residents of Oglala Lakota County, South Dakota, home of the Pine Ridge Indian Reservation, have a life expectancy similar to citizens of Iraq (66 years). 10 counties in rural Kentucky, however, led the list with the largest declines in lifespan over the past 20 years, followed closely by counties in rural Oklahoma and Florida. The difference between rich and poor counties in this study was absolutely striking—accounting for a two decade difference in average life expectancy. According to the authors, “Socioeconomic and race/ethnicity factors, behavioral and metabolic risk factors, and healthcare factors explained 60%, 74%, and 27% of county-level variation in life expectancy, respectively.” Dwyer-Lindgren, L., et al. (2017) Inequalities in Life Expectancy Among US Counties…JAMA Internal Medicine, 177, 1003-1011.
So let’s unpack this doleful sentence a bit. First it seems that there is a clear link between geography and lifespan in the U.S. Residents of poorer rural counties fare far less well than those of wealthier counties. It turns out that those who live in wealthy rural areas, like the ski areas of Colorado, are the luckiest, with an average lifespan of 86 years. Non-dominant ethnicity and lifespan are also negatively correlated. Native Americans and African Americans live shorter lives. However, this is not entirely an ethnic calculation—largely European-American residents of rural Kentucky tend to have the shortest lifespans of all. The clause “behavioral and metabolic risk factors,” the largest contributor to shortened lifespans at 74% of the variance, encompasses quite a bit—certainly, alcohol and drug misuse count highly here, as do poor diets, obesity, and lack of access to appropriate nutrition. Interestingly enough, as I discussed last month, the absolute contribution of the availability of healthcare is an important part of the equation, accounting for 27% of the variance, but not the largest factor. This supports the thesis that while healthcare is important, unless we simultaneously address other factors, such as rural poverty or access to affordable and nutritious food, we end up trying to create very expensive fixes that don’t address root problems.
In his 1941 State of the Union address, Franklin D. Roosevelt famously outlined four essential freedoms. The “Four Freedoms,” as the speech is now known, include the freedoms of speech, religion, and from fear, which we still hear much about today. The final, freedom from want, is something we hear less of these days. Given the clear linkages between poverty and shortened life span, perhaps this freedom should be given more attention. I think that the current situation might warrant consideration of an additional freedom, one that I believe may be a fundamental cause of declining lifespans: freedom from despair. We hear much about how opportunities for our children will not be as robust as were those for us or our parents. We read much about how such despair foreshortens ambition and entrepreneurial drive among impoverished rural Americans, as I reflected on after reading J.D. Vance’s Hillbilly Elegy in this column last year. Freedom from despair cannot be mandated, and cannot be enshrined in a constitutional amendment or legislation. But we know that it is there, and we know that we as a nation have successfully addressed and overcome it before. Healthcare should be seen as a long term investment, not as a political commodity. If we treat it as a political commodity, we deserve exactly what we are going to get. If we treat it as an antidote, however partial, to despair, we are investing in our future.
How to spend large portions of our national treasure is perforce a political decision and one worthy of robust debate. Some participants in this debate believe that healthcare should not be a crippling personal expenditure, and that the state should assist citizens in not only accessing affordable care but accessing those things that have shown to reduce healthcare expenditures, including many social and educational programs. As studies like Dwyer-Lindgren’s have shown us, access to healthcare is important, but unless we simultaneously address health-related behaviors, we will not appreciably fix the problem.
In closing, July 3 gave us an example of how ineluctably intertwined our profession is with the political process. On that date, the Oregon Senate followed their House of Representatives in approving a bill allowing appropriately trained psychologists to prescribe. After reconciliation, Oregon Governor Kate Brown is expected to sign the bill. This will make Oregon the sixth state authorizing psychologists to prescribe, and follows closely a vote in Idaho earlier this spring. New Mexico, Louisiana, Illinois, Iowa, Idaho and Oregon will have prescriptive authority. Of note, all of these states contain large, underserved, and often impoverished rural populations. If psychologists of all stripes, including those who can prescribe, can do something to address the healthcare needs of those rural citizens, then we will be doing our part to address the geographical healthcare disparities of American citizens.