The American Health Care Paradox, by Elizabeth H. Bradley and Lauren A. Taylor
In Review
The American Health Care Paradox
This may be one of the three most important books your member of Congress will probably never read.
The first is journalist T. R. Reid’s The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care (2009). A couple of hours with this book and Republican legislators might finally discover that most other economically advanced nations have systems that cost less than America’s, give better results and (shocker!) aren’t socialist.
The second is David Goldhill’s Catastrophic Care: How American Health Care Killed My Father—and How We Can Fix It (2013). Goldhill, who is both a CEO and a Democrat, offers a health-care proposal combining free-market business principles, personal responsibility and concern for the common good. A couple of hours with this book and Democratic legislators might realize that although the U.S. health-care system desperately needs fixing, Obamacare may not be the solution.
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The third book is neither as entertaining as Reid’s nor as concrete as Goldhill’s. But if the goal is to keep Americans as healthy as possible while spending no more than necessary, it may be the most important of the three, because it completely reframes the usual (and by now tedious) discussion. The American Health Care Paradox is a paradigm shifter.
Americans spend more on health care and get poorer results, say Elizabeth H. Bradley and Lauren A. Taylor, because we are coming at health care backward. Instead of investing in social services that help people stay healthy, America spends vast amounts trying to fix people after they have fallen ill. Until the U.S. reunites social and medical services as health-care partners, all the health-care legislation in the world will accomplish little.
The authors are well credentialed: Bradley is a professor of public health at Yale, and Taylor is a presidential scholar studying public health and medical ethics at Harvard Divinity School. Two years ago they attracted national attention with a New York Times article arguing that, contrary to popular opinion, America does not spend more than any other nation on health. If health care and social service expenditures—“like rent subsidies, employment-training programs, unemployment benefits, old-age pensions, family support and other services that can extend and improve life”—are looked at together, America’s total outlay is in tenth place (it has since fallen to 13th). And although most other industrialized nations spend two dollars on social services for every dollar spent on health care, America spends just 90 cents (now only 60 cents).
Sadly, the American tendency to medicalize health care seems not to be working so well. Bradley and Taylor tally the results of the U.S. approach:
Americans have lower life expectancy and higher rates of infant mortality, low weight birth, injuries and homicides, adolescent pregnancy and sexually transmitted diseases, HIV/AIDS, drug-related deaths, obesity, diabetes, heart disease, chronic lung disease, and disability than people in other industrialized countries.
Bradley and Taylor’s message, repeated in one form or another in every chapter, is that Americans need to start thinking seriously not just about how much money they are spending on health, but on how effectively they are spending it.
Readers hoping for a political way out of America’s health-care impasse (or for ammunition to support their partisan preferences) will be disappointed in this book, which is much more about why than how. The authors say they grimaced when they saw the title on the New York Times article presenting their position: “To Fix Health Care, Help the Poor.” They are not politically motivated, they say; nor are they advocating social justice. What they want to do is prompt Americans to reconceptualize health in order to maximize “the return on investment of our national expenditures.” Besides, they say, this isn’t just about the poor: “Americans who are white, insured, college educated, and upper income have poorer health than do their counterparts in other industrialized countries.”
Why has the United States chosen a costly system with less than stellar results? Bradley and Taylor offer an assortment of explanations for why Americans have put most of their eggs in the medical basket while ignoring the social services component of good health: a historical tradition of rugged individualism, a long-standing preference for voluntary rather than compulsory charity, a fear of government expansion, lobbying on the part of health-care providers who fear loss of revenue and “a mistaking of health care for health.”
Other countries have made different choices. The Scandinavian countries, for example, spend about twice as much of their gross domestic product on social services as the United States does, providing more government monies for “public education, health care, child allowances for families with children, pension rights, public housing support, and other social programs leading to improved welfare.” At the same time, they spend only half as much per capita on medical care, yet their life expectancy is higher than America’s, and their infant and maternal mortality rates are lower.
In a fascinating chapter, Bradley and Taylor explore attitudes that might help explain why countries that are similar in many respects have taken different paths. Scandinavians and Americans, their research showed, have similar attitudes toward personal freedom, science and technology, politics and competition. Scandinavians, however, focus more on the common good, while Americans are strongly individualistic. Scandinavians are less tolerant of income inequality. Perhaps most important, Scandinavians are more likely to trust one another—and their government.
Looking at other countries’ approaches to health care is just one of the ways Bradley and Taylor hammer home their message that an effective health-care system requires social even more than medical services. To show the importance of social services not only to the poor but also to seniors and to middle-class people with emergencies, they offer extended case histories. To demonstrate that social and medical services can learn to work together with good results, they describe an assortment of ongoing successful partnerships between hospitals and community care organizations, both public and private.
But the authors are not wildly optimistic that change is coming anytime soon. Various U.S. presidents, they note, have tried to increase America’s level of social services. Some, like Lyndon Johnson, have succeeded, but then others, like Richard Nixon, have undone their work. The reason is chilling, at least to those who suspect that the love of money might be the root of all evil:
Occupying 17.9 percent of the GDP in 2012 and employing one in eight working Americans, the health care industry returns significant profit for any number of professional guilds, health care organizations, and publicly traded corporations. If embracing a holistic vision of health and developing shared accountability results in a shift of funds from health care to social services or a repurposing of health care funds to achieve population health outcomes, a substantial number of Americans may stand to lose. As a result, a number of stakeholders and their political lobbies are likely to fiercely oppose and actively resist a flattening or redirecting of resources consumed by the industry.
Still, Bradley and Taylor hang on to hope. “If taxpayers understood that health was largely determined by nonmedical factors,” they say, “more strategic national investments that more efficiently align medical and nonmedical efforts to attain health might be possible.” Their book may help to increase that understanding.
First, though, someone needs to persuade Congress to stop posturing and start reading.
