Hartford - Getting more people covered by health insurance through the Affordable Care Act won't solve the persistent problem of health inequality.

Tackling that issue will be essential to bringing down health care costs and making this a healthier nation, said former Surgeon General Jocelyn Elders and other speakers last week at a forum sponsored by the nonprofit Connecticut Health Foundation, which works to improve the state's health through grants, policy research and other projects.

Lack of access to health care, which the Affordable Care Act aims to improve as more people get health insurance coverage, is only part of the problem. Research has found that the main factors in a person's overall health are social and economic, followed by the environment where they live and their genetics. Access to doctors and hospitals - or lack there of - accounts for only about 10 percent, Elders said.

Factors including the high stress of financial insecurity and living in high crime neighborhoods, along with lack of education about how to be healthy and language and cultural barriers, are major influences on whether a person is healthy and takes care of their health, Elders and other speakers said. It means shorter lives and higher rates of chronic illnesses such as diabetes, heart disease and asthma.

In the United States, medical care costs are now the world's highest at 18 percent of the gross domestic product, and the nation ranks among the least healthy of developed countries, according the World Health Organization.

"We have a health care system for the rich and a sick care system for the poor," said Elders, 80, who served a two-year tenure as surgeon general under former President Bill Clinton. A pediatrician and retired professor of pediatrics at the University of Arkansas, her term as surgeon general is most often remembered for her controversial remarks advocating that young people learn about birth control, masturbation and other sex education topics, remarks for which she has no regrets, she said.

"We live in a society where we can't talk about reproductive health, yet we complain about unplanned children," she said, adding that she continues to advocate for comprehensive health education from kindergarten through 12th grade. "America is not a sexually healthy nation. I didn't say anything (as surgeon general) that Bill Clinton hadn't heard me say 10 times when I was director of public health" in Arkansas.

Noting that "vows of abstinence break far more easily than condoms," Elders said she is proud of her efforts to promote sex education and condom use among youth.

"Today we have 331,000 (annual) births to teen mothers, and when I was surgeon general, it was 1 million. I want you to know I am proud of that. I want all children to be planned and wanted. And I've never heard of anyone to need an abortion who wasn't already pregnant."

While she addressed the topics for which she is best known, Elders didn't dwell on the past battles. Rather, she focused her remarks on the broader problem of health care disparities.

"Rich people get better medical care than poor people," she said.

Put another way, the reality is that people's health and the health care they receive depends greatly on their socioeconomic status.

"When people in our community get cancer, getting treatment can be the last thing on their list," said Grace Damio, director of research and service initiatives for the Hispanic Health Council. Patients who live in poverty, she said, often need assistance and care coordination to help them negotiate the complex medical care system.

She and others are concerned that once people get health insurance through the state's new Access Health CT marketplace, there won't be enough primary care doctors to care for them.

"Come Jan. 1, when everyone has an insurance card and starts looking for a primary care doctor, the fear is that everyone will end up at the emergency rooms," said Dr. Bruce Gould, associate dean for primary care at the University of Connecticut Medical School.

Lt. Gov. Nancy Wyman, who is overseeing the state's implementation of the Affordable Care Act, said the governor's office is looking to create a program to increase the number of primary care doctors and increase their reimbursement rates.

She acknowledged that getting more people covered by health insurance addresses only a piece of the complex problem of health inequities.

"Access Health CT is a marketplace, it's a place to buy insurance," she said. "It won't help people navigate through the health process."

j.benson@theday.com