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What You Don’t Know Can Hurt You

Wednesday, May 27, 2009

There is a strong association between educational attainment and health. That’s one more reason to empower Americans, not Washington, with greater ownership of their healthcare.

According to the Oxford Dictionary of Proverbs, the oldest written version of the saying “what you don’t know can’t hurt you” comes from 1576, in Petit Palace by G. Pettie. “So long as I know it not, it hurteth mee not.” More recent empirical research suggests the opposite, particularly when it comes to the relationship between levels of education and the likelihood of continuing to suffer from chronic and disabling pain.

Health policy researchers Steven Atlas and Jonathan Skinner report in a just-released National Bureau of Economic Research working paper that levels of education exerted a strong impact on changes in the pain experienced by older patients with lower back pain and sciatica over a ten-year period.

For example, they find that for those patients who were college graduates, just 9 percent of them reported leg or back pain “always” or “almost always” after 10 years, compared to 34 percent of those patients who lacked a high school degree. Of course, this sort of research finding remains preliminary, and some further statistical adjustments could squeeze that gap between the highest and lowest education groups. Atlas and Skinner examine other possible factors (such as occupation, industry, marital status, brain structure, social norms, and disability payment incentives) in the differences in the resolution of pain over time, despite objective evidence for the same underlying clinical condition, across the overall group of patients studied. However, the differences in pain outcomes by education seem to hold across the entire distribution of disabling pain (from little to mild to moderate to severe). 

This latest research is particularly interesting when placed in the larger context of earlier findings of a strong association between educational attainment and health, by such scholars as Angus Deaton, Adriana Lleras-Muney, and David Cutler; Michael Grossman; and Robert Kaestner. Just last month, the Robert Wood Johnson Foundation Commission to Build a Healthier America emphasized the importance of education in early childhood development and lifetime health.

 Miller_Lesser Education


Ironically, we are in the midst of another “historic” healthcare reform debate that again remains prone to focus more narrowly on the objectives of expanding more comprehensive insurance coverage to all Americans, and finding (or at least pretending to find) sufficient additional resources to finance the delivery of even more healthcare services to them.

Aside from a few rhetorical nods toward improving health behaviors in the general population and increasing information about healthcare choices, one still hears much more about Washington-determined rules, mandates, spending, and taxes to come than about how individual Americans might be empowered and assisted in taking more ownership of their personal healthcare decisions, such as through improved education, more actionable information resources, shared decision-making tools, and better-targeted incentives.

Earlier work by Skinner that examined the relative progressivity of benefits distributed within the seemingly uniform Medicare program suggested that better measures of the equity and efficiency of health policy should focus less on spending levels and more on health outcomes. While relative levels of health expenditures largely depend on preferences, health status, and prices, health outcomes are strongly influenced by health behavior, diet, and life-course events that extend beyond the healthcare system alone.

Can we avoid another painfully frustrating lesson in the limits of insurance-coverage expansions and more bloated public budgets alone? A quick trip back to reform school for health policymakers might teach them the value of refocusing on a broader portfolio of private and public investments in the education-related determinants of better lifetime health. Because what we don’t know really can hurt us.

But, in the meantime, take two more classes and call me in the next semester.

Thomas P. Miller is a resident fellow at the American Enterprise Institute. He is a former senior health economist for the Joint Economic Committee of the U.S. Congress and serves on the National Advisory Council for the Agency for Healthcare Research and Quality.

FURTHER READING: Miller wrote “ What DO We Know About the Uninsured?” and “Obama Healthcare 2.0,” on how the president’s opening offer of healthcare at a teaser rate fails to deliver what we actually need, value, and can afford.

Image by Darren Wamboldt/Bergman Group.

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