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Why the US spends so much on medical care -- revised

Posted by John McDonough  December 15, 2013 05:10 PM

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The longer one is in a field, that harder it gets to learn anything new. Old wine in new bottles, over and over.

Well, I've just finished reading a new book, The American Health Care Paradox, by Elizabeth Bradley and Lauren Taylor (previously reviewed in the Globe here). Thibradley4.jpgs is new and its central argument will change how I talk in the future about the dilemma of U.S. health care spending.

We all know the dilemma:

The U.S. pays so much more for medical care than does any other advanced nation, and from that societal investment, we get mediocre to poor results on life expectancy (26th place), infant mortality (31st), low birth weight (28th), maternal mortality (25th), you name it. It's been true since the early 1980s, and we keep looking for solutions from within the health care sector itself.

Maybe we've been barking up the wrong tree, as this chart from Bradley's research shows:


Bradley's research over the past several years examines spending on social services as well as spending on health care services in the equation.  She finds an important result. Though the U.S. spends the most on medical care among advanced (OECD) nations, we spend the absolute least (Mexico and Korea are our runners up) on non-health social services. When you put both together, we're not number one in spending, we're number ten. What kinds of social service spending are included:

"Social services expenditures included public and private spending on old-age pensions and support services for older adults, survivor benefits, disability and sickness cash benefits, family support, employment programmes (eg, public employment services and employment training), unemployment benefits, housing support (eg, rent subsidies) and other social policy areas excluding health expenditures."

Here's another way of looking at this phenomenon that illustrates how much of an outlier we are among our international peers:


It's lonely at the top, and in the middle, too!  Welcome to Outlierville.

And here's one more way to view where we stand showing the ratio of social to health services spending. We're the lowest, with only Mexico on our heels.


Something compelling is going on here. Bradley and Taylor write:

"Inadequate attention to and investment in services that address the broader determinants of health is the unnamed culprit behind why the United States spends so much on health care but continues to lag behind in health outcomes."


I can never consider U.S. macro-health spending again and ignore this piece of the puzzle. While many in the U.S. public health and social services sectors have recognized the chasm between the vast financial resources in the medical care sector versus the comparatively puny resources in the social services sector, Bradley's analysis puts it in a new and far more compelling light.

Our American tendency to medicalize everything we can get our hands on, while sometimes helpful for short-term problems, has accomplished far more harm than we realize. Our assumption that we can solve the U.S. health care dilemma from within the "house of health care" itself may be one of our saddest delusions.

This is not to belittle the efforts of those many, many men and women dedicated to the continuous and transformational improvement of medical care. Bradley's analysis, though, puts it in a different light. Fundamentally, the solution to the health care paradox cannot come from within health care itself.  It must come from outside, from public and political leadership at all levels, to get this straight.  Not just government, though very much from government.

[One note: the Bradley/Taylor book is stingy on methodology. For that, you need to go to Bradley et al's article, "Health and Social Services Expenditures: Associations with Health Outcomes" in BMJ Quality and Safety from March 29 2011 (20: 826-831).]

This blog is not written or edited by or the Boston Globe.
The author is solely responsible for the content.

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About the author

John E. McDonough is a professor of practice at the Harvard School of Public Health. He is the author of the book “Inside National Health Reform”, published in 2011 by More »


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