Why we spend more but get less
American society values access to doctors and the latest medical technology over social determinants of health.
When New York Mayor Michael Bloomberg proposed to limit sales of jumbo sodas in 2012, dissent on the banks of the Hudson could be heard clear down on the Mississippi Delta. The Mississippi legislature responded in 2013 with the so-called anti-Bloomberg bill, which forbids towns and cities from making such rules governing food and drink as restrictions on soda size or requirements to list calorie counts on menus. That’s in a state where one in three residents is obese—a circumstance that costs Mississippi an estimated $4.2 billion extra in medical costs each year.
For Elizabeth H. Bradley, Ph.D. ’96, professor of public health and director of the Yale Global Health Initiative, Americans’ narrow view of health maintenance combined with a culture of individualism explains why initiatives like Bloomberg’s raise hackles. With co-author Lauren A. Taylor, M.P.H. ’09, Bradley explores this hypothesis in a new book, The American Health Care Paradox: Why Spending More is Getting Us Less.
The paradox, of course, is that the United States spends far more on health care than do other developed countries; yet Americans have shorter life expectancies, lose more babies, suffer more often from diabetes and heart disease, are more likely to be obese, and so on.
Bradley and Taylor argue that one cause of the “spend more, get less” system is that Americans regard good health as synonymous with access to doctors. “Most of the evidence would say that medical care contributes 10 to 20 percent of health and well-being,” said Bradley in a recent interview, “but you would think that medical care determined 100 percent of our health.” This outlook, she said, “is very much aligned with having created a very big medical complex that is quite profitable for many of us: It’s 18 percent of our economy.”
The authors contend that doctors and patients alike seek medical care even for problems that could be solved through nonmedical means. In one case study, a physician pushes for surgery on a patient’s shoulder that heals successfully through physical therapy. In another, parents insist on one test after another to diagnose their teenager’s headaches, even after several doctors concur that the headaches arise from anxiety.
The United States has built its health care system on the assumption that people are largely responsible for their own welfare, said Bradley. As a counterpoint to American individualism, she and Taylor analyzed the attitudes of Scandinavians, who stay healthier while spending less. The authors found that Scandinavians are more open to collective action and far more willing to invest in projects beyond new hospital wings. “In Scandinavia,” Bradley said, “you could see left and right a broader understanding of the social determinants of health”—factors like the quality of housing, the richness of social support, safe streets, and urban design that promotes exercise. The American viewpoint, on the other hand, essentially reduces health care to a transaction between two individuals: a doctor and a patient. “It would be hard for a population with that basic culture [that is, American] to recognize and invest in the parts of our health that are collectively determined,” said Bradley.
But she said that American physicians interviewed embraced the need for change. “Doctors we talked with said, ‘I am in the emergency room with a patient who has diabetes, and I can’t even get to diabetes and wound care because the person has so many social issues. I’m not even able to do my job.’ ” If the American system addressed health more comprehensively, Bradley argued, doctors could be freed to do medicine, the profession they trained for, without feeling the need to be social service providers as well.