Americans are being treated poorly by their health care system, but the problem starts before someone walks into a doctor’s office or hospital.
There’s an underestimated contributor to America’s comparatively poor health: We don’t invest enough in social services that help people live healthier lives, and therefore overspend on healthcare compared to other developed countries.
Long-term trends in US healthcare, as I wrote earlier this week, tell a clear story: Medical outcomes have improved, and measures of life expectancy and burden of disease have improved in recent years. 25 years, but they haven’t gotten better. much as they have in other wealthy nations that spend less money on healthcare than the US.
According to a Kaiser Family Foundation Analysis of Health Care Trends 1991-2016, American life expectancy increased by 3.1 years during that period, a significant improvement, but substantially less than the 5.2 years gained in comparable countries. And for those average results, the US. spend more on health care: almost 18 percent of its GDP, compared to around 11 percent, on average, in comparable countries. Health spending has risen at the same rate in the US and its peers over the past few decades, and yet those other countries have seen more improvements in their health outcomes.
“One could conclude that the improvement in the value of comparable countries was greater,” wrote the KFF researchers in 2018, “even though they started with a higher threshold in terms of better results and a lower percentage of GDP consumed to achieve this. . “
There are many flaws to find within the US healthcare system itself: More people without health insurance than in other developed economies, higher prices for medical services and prescription drugs, higher out-of-pocket costs, etc. But there is another explanation for America’s poor health care performance.
If you combine spending on social services with spending on health, the US and its peers spend roughly the same amount of money (just over 30 percent of their respective GDP). But spending in those other countries leans more toward social support (food and housing subsidies, income assistance, etc.) while the United States spends more on health care.
Eighteen percent of people in the US live in poverty, compared to 10 percent in other rich countries. And we know that lower-income people face many structural challenges – lack of access to healthy food, clean water and fresh air to begin with – leading to worse health outcomes. When they get sick, they have a harder time finding a doctor and paying for their health care. In general, they also live with more stress and anxiety than people who earn more money, which also has deleterious effects on their health.
“Economic inequality is increasingly linked to disparities in life expectancy in income distribution, and these disparities appear to be increasing over time,” wrote the authors of a 2018 review of relevant research on Health matters. Poor health also contributes to lower incomes, creating a feedback loop known as the “health-poverty trap.”
How the United States is Slowly Trying to Improve Social Determinants of Health
These non-medical factors that have important consequences for a person’s health are known as social determinants of health. They describe the economic and social conditions that affect a person’s ability to live a healthy life. And they are also one of the characteristic failures of the US healthcare system.
Here’s another way to think about how American healthcare has gotten out of line on this issue, from a 2016 New England Journal of Medicine Article:
For decades, experts have described a profound imbalance between public funding for acute medical care and investments in the social and environmental determinants of health. By some estimates, more than 95% of the trillions of dollars spent on healthcare in the United States each year funds direct medical services, yet 60% of preventable deaths stem from modifiable behaviors and exposures that occur in the community.
This is also part of the US healthcare system, which is often ignored in the healthcare policy debate. Social determinants are the foundation of public health theory, but American politicians don’t always talk about food assistance, financial aid, or other wellness programs as part of their strategy to improve the nation’s health. Still, the two spheres are inextricably linked.
“We have decades, if not centuries, of evidence showing us that social determinants are really important in influencing health,” Amanda Brewster, a professor at the University of California at Berkeley who has studied the relationship between the two, told me.
That knowledge is beginning to further permeate the policy debate, as the health care industry itself notes that addressing structural contributors to people’s health is necessary to improve the long-term trends described above.
“What we’ve seen change is the interest in the healthcare sector in dealing with what to do with social determinants,” said Brewster, citing the shift to more value-based payment for healthcare as “one thing that helped spark creativity in healthcare providers and organizations about the variety of ways they could improve people’s health. “
One challenge is that, after decades of underinvestment in social supports, the United States doesn’t have many internal models of success to build on. Barring the sudden adoption of a Scandinavian-style social safety net, the United States must come up with its own strategy to improve the socioeconomic 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, less expectation that the government will help with these issues, more racial diversity, greater political polarization. , which pose a challenge to change the course of the social determinants of health.
“I don’t think it’s useless in the United States. We are incredibly innovative. Locally, we do all kinds of smart things, ”Bradley said. “But how to expand it in such a diverse country and with these racial divisions, that’s where we fall.”
It is also a resource problem. Because so much money is already being invested in health care, it is more difficult to pool the finances for new interventions that target the social determinants of health.
Even when the federal government has tried to invest more in such programs, the investment is usually small. The Affordable Care Act established a program called Responsible Health Communities, intended to fund pilot projects that would connect at-risk patients with more social supports. An early evaluation he found a modest reduction in hospital emergency room visits, but also found that the vast majority of participants did not last a full year in the program, and case managers cited difficulties staying in touch with enrollees .
It could also be said that it was a much smaller program than necessary. The AHC initiative was funded with about $ 157 million in five years. Brewster pointed out to me that under a statewide project in California that works toward the same goal, a single county received about $ 200 million.
The California project, the comprehensive individual care pilot program, was established in 2017 through Medicaid and received $ 3 billion for a five-year effort. It’s too early to say how much health is improving, but Brewster explained how it works to illustrate what better coordination between social services and medical spheres would look like.
In Contra Costa County, for example, the county integrated different data systems to identify which patients have complex needs and are most at risk of eventually developing serious medical problems. The patients are then assigned to a case manager. That person can help them sign up for housing or food assistance, connect them with a primary care doctor, and establish mental health support; in other words, establish a comprehensive care plan that goes beyond medical services. Patients can also receive a cell phone, free of charge, to make it easier for them to stay connected to the program.
“It’s not just about seeing your primary care doctor, it’s about this whole portfolio of things that we know are important to health,” said Brewster. “It really blurs the boundaries of these systems of care.”
At the start of the Covid-19 pandemic, the county recalibrated its data systems to identify those most at risk for serious illness from the new coronavirus. Case managers then reached out to prepare those people with food deliveries and other services that would help them shelter in place and reduce the risk of infection.
Brewster emphasized that we must have realistic expectations about what programs that focus on the social determinants of health can accomplish. They may not reduce total health spending, for example; In the United States, the problem is not that people use more medical services, but that the prices of those services are higher. The federal AHC program had a relatively modest effect, which may reflect the fact that the program was “too small, too late” for people who already had complex medical needs.
“These programs are not drugs,” he said. “They are complex interventions. They may work well in some places and less so in others. “
But in terms of improving people’s real health outcomes and long-term quality of life, this is one of the most promising frontiers in US health policy.