Seeking to peer through an opaque window

If you attempt to see through an opaque window, you will be confronted with a muted, reflected image of yourself, which is likely to be distorted. This is the dilemma facing the health and behavioral health care fields as they attempt to peer far beyond disease and health to questions of living and general well-being. In so doing, they are confronted only with themselves and the inherent limitations of our health and behavioral health care interventions. One could dub such efforts an attempt to medicalize everything.

This effort “from the inside outward” is bound to fail for several reasons. First, 80 to 90 percent of a person’s health status has nothing to do with either health or behavioral health care. Rather, it is due to one’s genetics, social and physical determinants, and lifestyle. Second, many factors in living and general well-being derive from the effects of the social and physical determinants upon our culture, communities, and families, and cannot be ameliorated or addressed by health care. As a pointed example, a child born into poverty will hear 30 million fewer words by age five than a child born into a middle class family. Clearly, the solution to this issue resides outside the scope of our health and behavioral health care systems.

What is driving our fields to peer into this opaque window? The Affordable Care Act (ACA) has unleashed an unprecedented level of creativity, innovation, and forward thinking. At the same time, it also has fostered unprecedented system changes, such as large-scale service integration and financial reforms, which are very anxiety provoking and threatening to health and behavioral health care providers. In the face of these threats, fear is driving efforts to extend the scope of activities covered by these providers.

To help understand these developments, it is important to note that our health care system already has moved from Healthcare 1.0—biomedical interventions—to Healthcare 2.0--biopsychosocial interventions--and now is on the cusp of moving to Healthcare 3.0--a framework that focuses upon healthy development over the life course.  It is in Healthcare 3.0 that we begin to encounter the inherent limits of health and behavioral health care, and confront the dilemma that health is related to all aspects of life.

To address this dilemma effectively, our health and behavioral health care fields will require a new paradigm. This paradigm shift can be developed through collaborative discussion and then communicated broadly throughout governmental, provider, and peer communities. The new paradigm will need to differentiate and link cultural/social interventions and health/behavioral health interventions.

A few key principles for developing this new paradigm would include:

• Healthcare should maintain appropriate scope. Our health and behavioral healthcare systems should ameliorate disease and foster recovery, prevent disease, and promote positive health through peer, clinical, and public health interventions. Such work also should extend to implementation of social supports needed to facilitate this primary goal.
• Healthcare should form needed partnerships for other endeavors. The negative social and physical determinants of health and their related lifestyle issues are problems in our culture, communities, and families that precede reduced health status and disease. Thus, they should be addressed by our institutions—government, business, education, and religion—that can have a direct impact upon them. Our health and behavioral health care systems should form partnerships with these institutions and support such efforts. For example, the problem of poor health due to a broad income gradient can be appropriately addressed by government, which can ameliorate it by increasing the minimum wage. Health care systems should support such efforts rather than attempt to address these determinants directly.
• Healthcare should measure well-being. As we undertake Healthcare 3.0, it will be essential to measure the status of both personal and community well-being. Well-being reflects the cumulative impact of all factors upon our physical, mental, emotional, and social health. Personal and community well-being measures can help us discern how well our interventions and partnerships actually are working.

Clearly, we can’t (and shouldn’t) medicalize everything; this only will lead to frustration. Key issues with the social and physical determinants of health that affect our culture, communities, and families are well beyond the scope and effect of our health and behavioral health care systems, and  require a new paradigm if they are to be addressed effectively.