Could This Yale Professor Have the Answers to Our Health Care Dilemma?

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

National Journal
Margot Sanger-Katz
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Margot Sanger-Katz
Feb. 26, 2014, midnight

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.

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