Americans get bad business with their healthcare system – but the problem starts before anyone walks into a doctor's office or hospital.
The comparatively poor health of the United States is underestimated: we invest too little in social services that help people lead healthier lives and therefore spend too much on medical care compared to other developed countries.
The long-term trends in U.S. healthcare that I wrote about earlier this week tell a clear story: medical outcomes have gotten better, with measurements of life expectancy and disease burden improving over the past 25 years, but they have not improving as much as other wealthy countries that spend less money on health care than the US.
According to an analysis of health trends by the Kaiser Family Foundation from 1991 to 2016, American life expectancy rose 3.1 years over that period – a significant improvement, but significantly less than the 5.2 years gained in comparable countries. And for those mediocre results, the US spends more on healthcare: nearly 18 percent of its GDP versus about 11 percent on average in comparable countries. Health care spending in the United States and its competitors have increased at the same rate over the past few decades, and yet, in these other countries, their health outcomes have improved.
“One could conclude from this that the increase in value of the comparable … countries was greater,” wrote the KFF researchers in 2018, “although they assumed a higher threshold for better results and a lower percentage of GDP was consumed for this. ”
There are many flaws to be found in the US healthcare system itself: higher numbers of uninsured than other developed economies, higher prices for medical services and prescription drugs, higher expenses, and so on. But there is another explanation for America's poor health care.
When you combine welfare spending with health care spending, the US and its peers spend roughly the same amount (just over 30 percent of their respective GDPs). But spending in these other countries is more focused on social assistance – food and housing benefits, income support, etc. – while America spends more on medical care.
Peterson-KFF Health System Tracker
Eighteen percent of the people in the United States live in poverty, compared with 10 percent in other rich countries. And we know that lower-income people face many structural challenges – first of all, lack of access to healthy food, clean water and fresh air – that lead to poorer health outcomes. When they get sick, they have a harder time finding a doctor and getting their medical care. In general, they also live with more stress and anxiety than people who make more money, which is also detrimental to their health.
"Economic inequality is increasingly associated with inequalities in life expectancy in the distribution of income, and these inequalities appear to increase over time," wrote the authors of a 2018 review of relevant research in Health Affairs. Poor health also contributes to lower incomes and creates a feedback loop known as the “health poverty trap”.
How the US is trying to improve the social determinants of health – slowly
These non-medical factors that have important effects on a person's health are known as social determinants of health. They describe the economic and social conditions that influence the ability to lead a healthy life. And they are also one of the characteristic flaws of the US healthcare system.
Here's another way to think about how American health care was misaligned on this topic from a 2016 New England Journal of Medicine article:
For decades, experts have described a profound imbalance between public funding for acute medicine and investments in upstream social and ecological determinants of health. According to some estimates, more than 95% of the trillion dollars spent on health care in the United States each year is funded by direct medical services, although 60% of preventable deaths are due to changeable behaviors and exposures in the community.
This is also a part of the US health system that is too often ignored in the health policy debate. Social determinants are a bedrock of public health theory, but US politicians don't always talk about food aid, financial aid, or other welfare programs as part of their strategy for improving the health of the country. Nevertheless, the two spheres are inextricably linked.
"We have decades, if not centuries, of evidence proving that social determinants are really important in influencing health," said Amanda Brewster, a professor at the University of California Berkeley who studied the relationship between the two.
This knowledge is increasingly permeating the political debate as the health industry itself signals that tackling structural factors that contribute to people's health is necessary to ameliorating the long-term trends described above.
"What we saw is the interest in the health care sector in addressing social determinants," Brewster said, citing the move to more value-based compensation in health care as "one thing that has helped fuel creativity in health care providers and organizations about ways in which they can improve people's health. "
One challenge is that, after decades of underinvestment in social support, the US does not have many internal models of success to build on. Aside from the sudden introduction of a Scandinavian-style social safety net, America must develop its own strategy for improving the socio-economic conditions that lead to poor health.
Vassar College President Elizabeth Bradley, who previously co-authored a book on the subject, told me that Americans have unique traits – strong individualism, fewer expectations that the government will help with these issues, more racial diversity, increasing political polarization – that is a pose of a challenge to turn the tide on the social determinants of health.
“I don't think it's hopeless in the US. We are incredibly innovative. At the local level, we do all kinds of clever things, ”said Bradley. "But as you can scale it in such a diverse country with these racial differences, that's where we fall together."
It's also a resource problem. With so much money already being poured into health care, it is more difficult to find the funding for new interventions that target the social determinants of health.
Even if the federal government has tried to invest more in such programs, the investments are usually small. The Affordable Care Act introduced a program called Accountable Health Communities to fund pilot projects that provide more social support to vulnerable patients. An early evaluation, while showing a modest reduction in hospital emergency rooms, also concluded that the vast majority of participants did not stay in the program for a full year, with case managers citing difficulties in staying in touch with participants.
It was probably a much smaller program than necessary. The AHC initiative was funded with around $ 157 million over five years. Brewster pointed out to me that a single county received about $ 200 million as part of a state project in California that works toward the same goal.
The California project, the Whole Person Care Pilot program, was launched by Medicaid in 2017 and funded with $ 3 billion for a five-year effort. It's too early to say how much it actually improves health, but Brewster explained how it works to illustrate what better coordination between social services and the medical field might look like.
For example, in Contra Costa County, the county has integrated various data systems to identify which patients have complex needs and who are at greatest risk of eventually developing serious medical problems. The patients are then assigned to a case manager. This person can help them sign up for housing or food aid, connect them with a family doctor, and set up psychological care – in other words, create a comprehensive care plan that goes beyond medical services. Patients can also get a cell phone free of charge to make it easier for them to keep in touch with the program.
"It's not just about seeing your GP, it's this whole portfolio of things that we know are important to your health," Brewster said. "It really blurs the boundaries of these supply systems."
At the beginning of the Covid-19 pandemic, the district recalibrated its data systems to identify people at a higher risk of serious illnesses from the novel coronavirus. Case managers then reached out to these people to provide food deliveries and other services that would help them stay in place and reduce their risk of infection.
Brewster stressed that we should have realistic expectations about what programs that target social determinants of health can achieve. For example, you must not reduce overall health expenditure; The problem in the US is not that people are getting more medical services, but that the prices for these services are higher. The federal AHC program had a relatively modest impact, possibly because the program was "too little, too late" for people with already complex medical needs.
"These programs are not drugs," she said. “These are complex interventions. They could work well in some places and not so well in others. "
But in terms of improving real health outcomes and people's long-term quality of life, this is one of the more promising frontiers of US health policy.