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
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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) Michael Marsland, Yale

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) Chelsea Williams

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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