Challenging Dogma

...Using social sciences to improve the practice of public health

Saturday, April 21, 2007

The Individual Mandate in MA mis-frames health insurance as the key to Reducing Morbidity and Mortality and Improving Overall Health – Julie Groth

Chapter 58 of the Acts of 2006 is a new law in Massachusetts that requires all residents to have health insurance. If people are not offered insurance from employers, they can purchase insurance from the connector. The connector is a public, central purchasing mechanism. It provides individuals with high quality insurance, which people can purchase using pre-tax dollars. The connector board is operated by the Group Insurance Commission and is overseen by appointed representatives. Individuals who are below a certain poverty level will not be penalized, and state funding programs will be set up to help these individuals receive health care at no cost to them. This includes the creation of the Health Safety Net Fund which will reimburse health care providers for uncompensated care. However, people who can afford insurance will be financially penalized for not having insurance. Insurance status will be listed on tax forms and will be verified through a database of insurance information. A major goal of the mandate is to reduce racial and ethnic health disparities (1). This mandate, which is supported by John McDonough, executive director of Health Care for All (2), is just a quick fix to universal coverage. Although many argue that universal health care coverage should be adopted in the United States, the issue of reducing morbidity and mortality is not actually addressed. Having health insurance does not improve the overall health of the population, and the new law in Massachusetts, which requires all residents to purchase health insurance, is not a substitute for improved health.

Social factors impact health

The new policy does not acknowledge social factors that have a greater impact on health, such as physical environment, discrimination, or availability of social support and resources. The physical environment is important to health. If people live in an area without a quality grocery store they are more likely to buy food from the cheap, unhealthy neighborhood grocery store. If the neighborhood has unsafe parks the residents will stay inside rather than exercise outside in the unsafe park. If people are not surrounded by healthy options, they will be forced to make unhealthy decisions. For example, if a neighborhood has seven fast food restaurants and one grocery store that sells expensive organic food, people are more likely to eat fast food because it is cheaper and faster. Living in an environment with poor conditions is unfavorable to health.

If people are surrounded by littered areas and buildings covered in graffiti, they are likely to live in an area high in crime. “According to James Wilson and George Kelling’s Broken Windows Theory, if a window is broken and left un-repaired, people walking by will conclude that no one cares and no one is in charge. Soon, more windows will be broken, and the sense of anarchy will spread from the building to the street, sending a signal that anything goes. In a city, relatively minor problems like graffiti, public disorder, and aggressive panhandling are all the equivalent of broken windows, invitations to more serious crimes” (3). Living in areas with high crime is not good for one’s mental health. A study published by Princeton University and Harvard University found significant mental health benefits for individuals who were given housing vouchers to move into private housing units, which were cleaner environments than their previous residences in the public housing projects. The study also found a significant reduction in obesity for these individuals (4).

Social support and resources are also important factors that affect health. Quality social interactions are important for health. An increased amount of social interaction is associated with lower levels of mortality and depressive symptoms (5). The mandate does not address the issue of social structures and social norms. Instead of mandating insurance, there should be an emphasis on improving community networks and encouraging healthy decisions to become the social norms. This will lead to a lower need for expensive medical treatments. This can be done by training people in the community, like nurses or beauticians, to change social norms that are beneficial to the community. For example, a nurse named Georgia Sadler began a campaign to increase knowledge and awareness of diabetes and breast cancer in the black community of San Diego. She originally gave her message in black churches but was not getting the message through to many members of the community. Then she realized she needed to change the context of her message. After church, people are tired and hungry, so Georgia thought of a place where people spend a lot of time and aren’t stressed - beauty salons. By training hairstylists to spread awareness of diabetes and breast cancer, Georgia found her program to be very successful. The beauticians changed social attitudes, and women began to have mammograms and diabetes tests (6). Georgia’s efforts changed social norms in a group that has traditionally felt discrimination from health professionals.

Discrimination is another social factor that influences health. There is a buildup of mistrust of medical professionals by certain minority communities, especially by African Americans (7). This mistrust is likely rooted in slavery, segregation, and unethical studies, like Tuskegee, that were harmful to the participants of certain minorities (7). Discrimination from health professionals adds to the stress level of the discriminated people, which is bad for their mental and physical health (8). It is pointless for people who do not want to visit the doctor to be forced to purchase health insurance because they may not wish to be treated. The new mandate does not address this issue of discrimination and the unwillingness of certain people to visit doctors in the current health system. The law assumes people want medical care from doctors when some people really do not trust the medical profession and have no desire to see a doctor. Therefore, it would be more beneficial to first invest in improving and encouraging strong, trusting patient-physician relationships before requiring everyone to make an investment in the current health care system.

The importance of social factors in improving health status is vast. To demonstrate this importance, Malcolm Gladwell summarizes a statement made by an epidemiologist who was primarily concerned with fighting the AIDS epidemic. He says, “The AIDS epidemic is fundamentally a social phenomenon[…] We might have halted the spread of AIDS far more effectively just by focusing on the beliefs and social structures and poverty and prejudices and personalities of a community, rather than getting caught up in the biologic characteristics of AIDS” (9). The individual mandate gets too caught up in the biological characteristics, because it focuses on the medical system rather than trying to improve important social factors that affect health.

Decrease in disposable income created by the new law

Requiring people who may have trouble affording insurance to purchase it will reduce their income that they could have spent on healthy food, a gym membership, or other things that could improve their health. Some people do not need expensive medical treatment to be healthy and choose not to purchase health insurance. For example, Jerry, a 59 year-old lawyer from Minnesota, has not had health insurance for the past four years. He had not been treated by a doctor in 40 years and unless he incurred at least $15, 000 worth of medical expenses in a year, it was not worth his money to pay for health insurance. He has a healthy diet, exercises at a gym regularly, and takes nutritional supplements. He thinks if a similar mandate passed in Minnesota he would feel oppressed, irritated, and disgusted. However, since he is a law abiding citizen, he would purchase health insurance. This new expense would require him to cut something out, and he would most likely cut out dental and eye care expenses (10). Good eye and dental care are important for maintaining a higher quality of health. If other people respond to the law like Jerry, the health status of the Massachusetts population might decline rather than improve. Additionally, the new insurance plans offered by the connector may have high deductibles and co-pays. Like Jerry, many families would be required to make less healthy decisions or even forego certain care in order to pay for insurance.

Socioeconomic Status (SES) is a key predictor of health. A study of Canadian males showed income was consistently the best correlate of health status of three SES factors – education, occupation, income. The study found a positive relationship between SES and health status, which means the higher a person’s SES the higher that person’s health status (11). The individual mandate does not improve a person’s SES. Instead it will put everyone at the same level in terms of having health insurance. Even in a county like Canada, where everyone has national health insurance, SES still affects health status. Because this law will require some residents to add an expense to their budget, it will not effectively improve SES for those individuals who are initially at a low SES.

Some people maintain health by spending money on healthy food, gym memberships, and nutritional supplements. It is unnecessary to spend money on insurance if people are able to make healthy life decisions instead. The mandate will not effectively improve health, because people will be forced to cut out healthy options from their budget.

Insurance is not the only access to care barrier

Forcing health insurance on all individuals is not sufficient, because there are still barriers to health care once a person has insurance. For example, there may not be interpreters in the hospital, the insurance plan may have large deductibles and co-pays, or waiting lines may be lengthy. Katie Wellstooda, Kathi Wilsona, and John Eyles conducted in-depth interviews of 41 Canadian men and women. The researchers asked the participants about barriers to health care they had experienced and classified the barriers as either individual or system barriers. Of the 41 participants interviewed, 32 mentioned either system or individual barriers in trying to access health care through their family doctors. System barriers were mentioned more than twice as often as individual barriers with waiting time in the doctor’s office being the most cited system barrier. Geographic location and limited hours of operation were the next two cited examples of system barriers (12). A goal of the mandate is to have at least 99 percent of the Massachusetts population insured (13). If close to everyone is insured, then people will start seeking medical care for symptoms, like a sore throat, when they normally would not have visited a doctor. This will cause an increase in the waiting times to visit physicians and therefore only increase the likelihood of other people avoiding healthcare because of an increase in system barriers when they actually may need it.

Large deductibles and co-pays are another barrier to care. For Annabelle Blake, a Massachusetts resident with a $30,000 income, the cheapest insurance plan offered by the connector will cost $174 per month (14). With the $2,000 deductible, she will have to use seven percent of her income on medical expenses. This does not include medications or the amount she spends each month on her premium. A person should not be spending over seven percent of their income on medical expenses, like Annabelle would have to do with the new insurance plan. Cost is an important factor when deciding to purchase insurance. Although the new law attempts to make cost less of an issue, it still will be for many people.

Also, once people are in hospitals or other places to receive health care, they may not be able to effectively communicate with the health professionals. The rate of use of interpreters is not impressive. “According to one study, no interpreter was used in 46 percent of emergency department cases involving patients with limited English proficiency (15).” This is a huge problem. People who face language barriers often do not follow medical advice and have higher rates of hospitalization and drug complications (15). The law tries to improve access to care as a means to improving health; however, several other important barriers to health care are not addressed.

Will the law help?

Having health insurance does not improve the overall health of the population, and the new law in Massachusetts, which requires all residents to purchase health insurance, is not a substitute for improved health. The law does not address social factors, expenses, and other access to care barriers, so it is unlikely the individual mandate will improve health in Massachusetts. The makers of the law did not pay attention to the study supported by the National Bureau of Economic Research that shows little evidence that Medicaid improves the health of children (16). This is one of a few studies that shows that health insurance does not improve health. The individual mandate has an important goal of improving health and decreasing health disparities, but does not approach the goal from an appropriate angle.


1. Greenberger, S. (2005, October 30). Health plan pressures Mass. firms; House bill: insure workers or pay state. Boston Globe, Accessed on April 18, 2007 from
2. Belluck, P. (2007, April 12). Massachusetts offers details on health coverage. New York Times, Accessed on April 13, 2007 from
3. Gladwell, M. (2002). The tipping point: How little things make a big difference. New York, NY: Little, Brown and Company.
4. Kling, J. R., Liebman, J. B., Katz, L. F., & Sanbonmatsu, L. (2004). Moving to opportunity and tranquility: Neighborhood effects on adult economic self-sufficiency and health from a randomized housing voucher experiment. National Bureau of Economic Research. JEL I18, I38, J38. Accessed on April 3, 2007 from
5. Cohen, S., Brissette, I., Skoner, D. P., & Doyle, W. J. (2000). Social integration and health: The case of the common cold. Journal of Social Structure, 1, Accessed on April 17, 2007 from
6. Gladwell, M. (2002). The tipping point: How little things make a big difference. New York, NY: Little, Brown and Company.
7. Watts, R. (2003). Race consciousness and the health of African Americans. Online Journal of Issues in Nursing. 8 (1), Manuscript 3. Accessed on April 17, 2007 from
8. Borrell, L. N., Kiefe, C. I., Williams, D. R., Diez-Roux, A. V., & Gordon-Larsen, P. (2006). Self-reported health, perceived racial discrimination, and skin color in African Americans in the CARDIA study. Social Science & Medicine. 63, 1415–1427.
9. Gladwell, M. (2002). The tipping point: How little things make a big difference. New York, NY: Little, Brown and Company.
10. D. Turbak, email interview, April, 3, 2007
11. Hay, D. I. (1988).Socioeconomic status and health status: A study of males in the Canada health survey. Social Science & Medicine. 27 (12), 1317-1325.
12. Wellstood, K., Wilson, K., & Eyles, J. (2006). ‘Reasonable access’ to primary care: Assessing the role of individual and system characteristics. Health & Place. 12 (2), 121-130.
13. Belluck, P. (2007, April 12). Massachusetts offers details on health coverage. New York Times, Accessed on April 13, 2007 from
14. Dembner, A. (2007, March 24). Facing up to insurance changes. The Boston Globe, Accessed on April 3, 2007 from
15. Flores, G. (2006).Language barriers to health care in the United States. New England Journal of Medicine. 355, 229-231.
16. Kaestner, R. J., Joyce, T. & Racine, A. (1999). "Does Publicly Provided Health Insurance Improve the Health of Low-Income Children in the United States" NBER Working Paper No. W6887. Accessed on March 14, 2007 from

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  • At May 4, 2007 at 2:11 PM , Anonymous Anonymous said...

    Well-written "health" food for thought that demonstrates and raises the debate about solving problems by throwing money at them. The issues she identifies outside of health insurance for improving health are obvious, but it's not as sexy as mandating insurance. Another question may be posed by this mandate: who benefits by having mandatory insurance? 1) Insurance companies who get more subscribers; 2) the health care profession that can now collect from insurance companies instead of folks who couldn't pay before; and 3) the state which can now sue its residents for not having insurance, thereby reniging on the social welfare that we all must carry.


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