Spending More and Getting Less for Health Care

The cover of "The American Health Care Paradox"
Pauline W. Chen, M.D.

The patient, lean and in his 60s, was in the hospital for the second time in a month with blood sugar levels that were out of control and he was not happy. Despite the nurses’ earnest attempts to cheer him up, he scowled and insisted that all he needed was for us to “fix it” so he could go back home.

“We have to keep looking because you may have other serious problems that caused your blood sugar to go up,” I said, preparing to rattle off a list of potential causes.

“You bet I have other problems, Doc,” he growled back. I watched the color in his face rise as he described the death of one of his adult children in a car accident several years earlier. His mouth quivered as he spoke of another child who had became seriously disabled while fighting in the military. And his eyes teared up as he described losing his job as a custodian at a local office building.

“I can’t pay for my medications, I can’t do enough for my son, and I miss my baby,” he said, now weeping.

At that moment, I knew that I could diagnose as much as I wanted, prescribe, operate and enlist the help of an army of primary care and specialty colleagues; but he would be back. Whatever the reason for his elevated blood sugar levels this time, sooner or later his grief would envelop him, he would be overwhelmed with his caretaking duties or he would run out of money for his medications, and he would be back at the hospital once more.

What I could take care of was only the tip of his health care concerns.

 

I remembered this patient, and many more like him that I have encountered in practice, while reading a new book,“The American Health Care Paradox.”

Studies since the 1980s have shown that despite spending enormous sums on health care, Americans are less healthy than their counterparts in other developed countries. In the most recent studies comparing the United States to 17 other wealthy industrialized nations including France, Japan, Canada and Britain, Americans had a shorter life expectancy, higher rates of disease, the highest rates of infant mortality and the lowest chance over all of surviving to middle age.

These dismal findings have so befuddled health care experts, policymakers and politicians that they have come to be known simply as “the American health care paradox,” or among the more candid, “the U.S. healthcare disadvantage.” Some experts have attributed the abysmal outcomes to the greed, waste and inefficiency of the payment system, practitioners and the pharmaceutical industry. Others have postulated that the lack of patient access and the American desire for the most sophisticated and newest therapy are the reasons. Still others have pointed to the American malpractice system as a key culprit.

Dr. Elizabeth H. Bradley

Dr. Elizabeth H. BradleyCredit Michael Marsland, Yale University

But in 2011, in a well-respected professional journal and in The New York Times, Dr. Elizabeth H. Bradley, director of Yale University’s Global Health Leadership Institute, Lauren A. Taylor, a former program manager at the institute, and their colleagues offered one of the most compelling and cohesive explanations yet.

Lauren A. Taylor

Lauren A. TaylorCredit Chelsea Williams

As with other researchers, they had found that the United States spends a significantly higher percentage of its gross domestic product — as much as 50 percent more than other developed countries — on health services like acute hospital care, rehabilitative care, diagnostic imaging, laboratory tests and health insurance. But when that percentage is combined with the much smaller amounts spent on education, old age pensions, disability and sickness benefits, family support and employment programs, unemployment benefits and housing support, the United States ranking drops precipitously to one more in line with its poor health care outcomes.

In other words, the reason the richest country in the world doesn’t have the best health is because it takes more than health care to make a country healthy.

Now in their new book, Dr. Bradley and Ms. Taylor expand on these findings. And while a 272-page book based on a six-page journal article might seem like the literary equivalent of a one-song band, “The American Health Care Paradox” has enough intellectual heft to bring an opera house to its feet. Drawing on data from dozens of international and domestic site visits, wide-ranging scholarly studies and in-depth interviews with patients, practitioners, health care administrators and social service staff from all over the world, the authors tackle the unenviable task of explaining why we think of health care the way we do — to the near total exclusion of social services.

And they manage to do it with astonishing clarity, conciseness and narrative ease.

In a single chapter, for example, the authors review the critical historical and cultural turning points of American medicine and social services and show how in the United States these two sectors developed along markedly different paths. Health care became a profitable industry, with powerful special interest groups battling each other for the spoils. Social services, on the other hand, fell into the domain of government agencies and a handful of nonprofit organizations, utilized by only those who couldn’t afford care otherwise. In a country that continued to cling to the ideal of rugged individualism, reliance on such services came to be seen as evidence of a person’s weakness and a sign of financial and moral impoverishment.

As the authors remind us, Ronald Reagan once famously declared the nine most terrifying words in the English language as being, “I’m from the government and I’m here to help.”

While chapters of the book are devoted to real-life patient stories, descriptions of innovative American programs that manage to integrate health and social services and, yes, the recounting yet again of the successes of Scandinavian countries in balancing the two, the most thought-provoking writing focuses on America’s previous attempts to integrate social services and health care delivery. It is a sobering list of near-misses and “what-if’s,” testimony to the intractable power of cultural attitudes.

Among the casualties described are the neighborhood health centers envisioned in the 1960s and early ’70s as “a flexible, community-based center of comprehensive care” where all Americans could receive their health care and, if needed, access housing agencies, job training and other support services, too. The centers were an astounding success; but that success quickly drew the attention, then ire, of the American Medical Association and of politicians and policymakers who warned that such government-supported centers were intruding on individuals’ private lives. Powerful lobbying groups eventually exerted enough political pressure to force politicians to cut the centers’ funding to the point where they became nothing more than “dispensaries of medical care primarily for indigent people.”

“These complex histories reveal an American tendency to funnel resources earmarked for health toward medical care,” the authors write. And “these historical realities make clear that Americans have been complicit in the creation of the current approach.”

American health care history abounds with examples of this complicity, lost opportunities and health care gone wrong; and Dr. Bradley and Ms. Taylor make no effort to adorn the dismal details. They offer no straightforward solutions, and after finishing the book, it is hard not to throw one’s hands up in defeat.

But it is also hard to ignore the enormous funding and reimbursement disparities between high-tech diagnostic procedures like M.R.I.’s and intensive care on the one hand, and housing support, education and job training on the other. It is difficult to accept all the lost potential for an inclusive and holistic approach in policy proposals and health care plans. And it becomes clearer than ever after reading the book how even in our own lives, doctors, medicine and all the latest treatments are not the only things that keep us healthy.

And that may just be the point.

New York Times