Why the Health Care Paradox Is About Inequities

The best way to address disparities might be to look outside hospital walls — and focus on early-childhood development and education

The United States has the most expensive health care system in the world, and yet we still have shockingly poor outcomes and broad inequities in the way our population’s health is distributed. Policymakers seeking to boost quality and trim the budget have long looked at the functioning of our medical care system, but a new book from Yale public health professor Elizabeth Bradley and her coauthor, Lauren Taylor, argue that our country would be better off looking outside the hospital walls.

In their new book, The American Health Care Paradox, they explore how the rest of the Western world invests in health care and found that many nations are lowering health spending by putting their dollars into other social-services programs — in areas like education, housing, and transportation. The book argues that the U.S. might be able to improve health and lower its spending by doing the same. Spending on services for the low-income and often heavily minority communities with the most daunting challenges, their works suggests, is a better public investment than pouring health care dollars into treating the consequences after the fact.

The book was launched, in part by a buzzy New York Times 2011 op-ed on their research titled “ To Fix Health, Help the Poor,” but Bradley insists that her proposals are not those of “bleeding-heart liberal health people,” but instead observations designed to improve the efficiency of the U.S. system.

Your book is called The American Health Care Paradox. What is the paradox you’re talking about?

Elizabeth Bradley, interviewed here as coauthor of The American Health Care Paradox, is director of the Yale Global Health Initiative. She holds a bachelor’s from Harvard, an M.B.A. from the University of Chicago, and a doctorate from Yale. (Michael Marsland, Yale)The paradox we’re talking about is the fact that in the United States we spend double as much as a country as the average high-income country in the world, and yet our health outcomes are among the very worst. So how could we be spending so much money and not getting as good health in our population as other countries? That’s really the paradox: The more you spend, the less you get.

We’re so frequently hearing that the U.S. has the best health care system in the world. What are the measures you’re using to say we’re not as good as in the rest of the world?

The measures that we used span a very large scope. Some of them are very broad measures like infant mortality, low birth weight, life expectancy, premature death, maternal mortality. But some of them are more specific to a disease, such as the prevalence of heart disease, diabetes, disability days, HIV, sexually transmitted diseases [laughs], teenage birth rates. So it really cuts a large swath.

But the truth is, if we look at some of these other outcomes that are very medically oriented, we do have the best system in the world. For instance, if you do have diabetes, you are more likely to see a specialist in a quicker time than anywhere else in the world. For a senior who needs a hip replacement, they will get that fast and well. So there are many things about our health care system that are the best in the world. It’s just not always the same things that measure health.

Your research really zoomed out to look at what countries spend on health outside the clinic walls, and on things like housing and education. What did the numbers show about these investments in social services?

Lauren Taylor, Bradley’s coauthor, is a presidential scholar of public health and medical ethics at Harvard Divinity School and is former program manager at the Yale Global Health Leadership Institute. (Chelsea Williams)It does seem counterintuitive to a culture that has a strong medical care system. 

The best way to think about this is that, in the U.S., for every dollar we spend on health care, we spend about 55 cents on these other social services. If we go to Western Europe, particularly Scandinavia, for every dollar they spend on health care, they spend 2 [dollars] on social services. It’s almost inverted. It’s really quite dramatic.

Why do you think that social-service spending turns out to be so much more cost effective than health care spending? It seems a little counterintuitive.

In determinants of several very common chronic diseases, we see something very different. Seventy percent of colon cancer and stroke is really heavily contributed to by nutrition, exercise, sleep, stress, work environment — social and behavioral factors. And people say 80 percent of heart disease is strongly tied to these factors, 90 percent of adult onset of diabetes. We tend to see it at the very end, when the person has the acute event. They have a heart attack, and they need to go to the hospital. And of course at that time, the angioplasty is the thing, but if we were to look at the lifetime, we would say, “Well, it had nothing to do with the angioplasty.” It had to do with what the person was eating and the exercise and the kind of stress environment they had, and the kind of housing they had, and education.

Most of your early research was on how to improve the quality of medical care? How did you come to this project, focused on the nonmedical side of things?

Always in the back of my mind was that no matter how good our medical system is, we are still not as healthy a population. I got to a point, I was teaching a course in the history of health policy and really started thinking to myself: Why has this statistic been here for 30 years? We’re just spending so much, but we’re not getting so much, and that’s when it really hit me: OK, quality of medical care is important, but it’s not everything.

In your book, you call for a greater coordination between the provision of health care and other services, such as housing and food and transportation. Are these services typically bundled together in other countries? Why don’t you think they are in the U.S.?

In our successful countries, particularly Scandinavia, yes, these are bundled together and the budgeting process is one that happens at the county level, in which the county authority has the full bundled budget to decide how much of this do we spend in education, and how much do we spend in health care. Now, we are not Scandinavians. We do not have the values that are the same; we are not as homogeneous. We’re much bigger. Lots and lots of reasons.

But aside from those demographic and cultural reasons in the U.S., our decisions about social services tend to be made very locally, and our decisions about health care services tend to be made at the state or federal level or at the employer level. In other countries, the health care system and the social-service system are being made at the same level, the decisions, and by the same people and in the same public purview. At the U.S., we have complete fragmentation about how these decisions are being made.

Is there a way the U.S. could be spending the money on this sort of bundled health care and social services more effectively?

Absolutely. There is no question in my mind we could be doing this better and more cost effectively. We have had a fair number of people who are really concerned about spending, and Republicans in nature who really liked the book because it’s expedient. For example, we profile certain programs where people are coordinating between a major academic medical center and a community center to say we have a joint problem. You really need to house these people, and we in the hospital really need to take care of them when they’re in emergencies, but we’re really getting all these people in the emergency room when they need housing. How can we coordinate with each other in a way that’s win-win and we are seeing benefits?

How much of the U.S.’s health care disparity problem is really about poverty?

How much does poverty really explain all of this? Two things here. One is certainly the group of people who are in the safety net and are of very, very low income; this is a very expensive group in the health system, and we can absolutely do better and have a win-win situation. That is true. Would that be enough? I don’t think that would be enough.

If you could be queen for a day, and you didn’t have to worry about budgetary constraints, and you didn’t have to worry about politics, what would you change about the way the U.S. government spends money on health care and social services?

This is if you didn’t have to worry about politics?

Yes, you are the queen.

It’s hard to disentangle from the cultural politics we have. I know if I was Scandinavian what I would do. But if we had to do this with an American voice and American values, I think it has to do with making those who are receiving the health care dollar more accountable for the social determinants. So doctors and nurses are thinking hard about not just, “Have I given them their beta blocker?” but, “Are you getting the food, do you have a job that is reasonable, are our streets safe?” Maybe the board of trustees of the hospital would be more enthusiastic about being on the local job-training board. In other words, giving the health care dollars more incentive to think about things other than medicine that keep us healthy.

If you pressed and said here are the six key social services that we spent the most money on, the one you’d always go to spend more money on would be early-childhood development and education. The payback for that is fabulous.

National Journal