A welfare line in New Jersey |
By Elizabeth H. Bradley and Lauren Taylor, The New York Times, December 8, 2011
IT’S common knowledge that the United States spends more than any
other country on health care but still ranks in the bottom half of
industrialized countries in outcomes like life expectancy and infant mortality.
Why are these other countries beating us if we spend so much more? The truth is
that we may not be spending more — it all depends on what you count.
In our comparative study of 30 industrialized countries, published
earlier this year in the journal BMJ Quality and Safety, we broadened the scope
of traditional health care industry analyses to include spending on social
services, like rent subsidies, employment-training programs, unemployment
benefits, old-age pensions, family support and other services that can extend
and improve life.
We studied 10 years’ worth of data and found that if you counted the
combined investment in health care and social services, the United States no
longer spent the most money — far from it. In 2005, for example, the United
States devoted only 29 percent of gross domestic product to health and social
services combined, while countries like Sweden, France, the Netherlands,
Belgium and Denmark dedicated 33 percent to 38 percent of their G.D.P. to the
combination. We came in 10th.
What’s more, America is one of only three industrialized countries to
spend the majority of its health and social services budget on health care
itself. For every dollar we spend on health care, we spend an additional 90
cents on social services. In our peer countries, for every dollar spent on health
care, an additional $2 is spent on social services. So not only are we spending
less, we’re allocating our resources disproportionately on health care.
Our study found that countries with high health care spending relative
to social spending had lower life expectancy and higher infant mortality than
countries that favored social spending. While the stagnating life expectancy in
the United States remains at 78 years, in many European countries it has leapt
to well over 80 years, and several countries boast infant mortality rates
approximately half of ours. In a national survey conducted by the Robert Wood
Johnson Foundation, four out of five physicians agreed that unmet social needs
led directly to worse health.
Unfortunately, instead of learning from countries like Sweden and
France, we prefer the frantic scramble to recover money from one part of the
health care system only to reallocate it toward retreads of previously failed
reforms. We pretend that the fresh schemes are innovative, but they are usually
long on promises, short on details and often marked with an annoying acronym:
H.M.O., F.S.A., A.C.O. and so forth.
It’s time to think more broadly about where to find leverage for
achieving a healthier society. One way would be to invest more heavily in social
services. This may be difficult for many Americans to swallow as it suggests a
potentially expanded role for government. Out of respect for individuals’
rights, our current social programs are mostly opt-in, leaving holes for the
undocumented, uneducated and unemployed to slip through cracks and become
acutely ill. Emergency rooms, though, are not allowed to opt out of providing
these people extraordinarily expensive medical treatment before discharging
them back to wretched conditions and their inevitable return to the E.R.
The impact of sub-par social conditions on health has been well
documented. Homelessness isn’t typically thought of as a medical problem, but
it often precludes good nutrition, personal hygiene and basic first aid, and it
increases the risks of frostbite, leg ulcers, upper respiratory infections and
trauma from muggings, beatings and rape. The Boston Health Care for the
Homeless Program tracked the medical expenses of 119 chronically homeless
people for several years. In one five-year period, the group accounted for
18,834 emergency room visits estimated to cost $12.7 million.
We can learn from the star pupils in our analysis. Other countries
have created government ministries that marry health and social care. Earlier
this year, the Department of Health in Britain released plans to create health
and well-being boards comprising local government representatives, primary care
physicians, hospital administrators, children and adult-services specialists
and public health directors, who will coordinate care for their constituencies
across the health and social care spectrum. We should think expansively about
how to construct similar programs that enable much needed integration of these
mutually dependent sectors. The Department of Veterans Affairs is leading the
way, with programs called “stand downs” that simultaneously address the health
and social needs of retired service members.
It is Americans’ prerogative to continually vote down the encroachment
of government programs on our free-market ideology, but recognizing the health
effects of our disdain for comprehensive safety nets may well be the key to
unraveling the “spend more, get less” paradox. Before we spend even more money,
we should consider allocating it differently.
Elizabeth H. Bradley is professor of public
health at Yale and faculty director of its Global Health Leadership Institute,
where Lauren Taylor is a program manager.
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