Americans are getting a bad deal from their health care system — but the problem starts before anybody ever steps into a doctor’s office or a hospital.
There is an underappreciated contributor to the United States’ comparatively poor health: We underinvest in social services that help people live healthier lives and therefore overspend on medical care relative to other developed countries.
The long-term trends in US health care, as I wrote about earlier this week, tell a clear story: Medical outcomes have gotten better, with measures of life expectancy and disease burden improving over the last 25 years, but they haven’t improved as much as they have in other wealthy nations that spend less money on health care than the US.
According to a Kaiser Family Foundation analysis of health care trends from 1991 to 2016, American life expectancy rose by 3.1 years during that period — a meaningful improvement, but substantially less than the 5.2 years gained in comparable countries. And for those middling outcomes, the US spends more on health care: nearly 18 percent of its GDP, versus about 11 percent, on average, in comparable nations. Health spending has been rising at the same rate in the US and its peers over the last few decades, and yet those other countries have seen more improvement in their health outcomes.
“One could conclude that the comparable ... countries’ value improvement was greater,” the KFF researchers wrote in 2018, “even though they started at a higher threshold in terms of better outcomes and a lower percentage of GDP consumed to achieve it.”
There is plenty of fault to find within the US health system itself: a larger number of uninsured people than in other developed economies, higher prices for medical services and prescription drugs, greater out-of-pocket costs, and so on. But there is another explanation for America’s poor health care performance.
If you combine social services spending with health spending, the US and its peers spend about the same amount of money (a little more than 30 percent of their respective GDPs). But spending in those other countries is weighted more toward social support — food and housing subsidies, income assistance, etc. — whereas America spends more on medical care.
Eighteen percent of people in the US live in poverty, compared with 10 percent in other wealthy countries. And we know that people with lower incomes face many structural challenges — lack of access to healthy food, clean water, and fresh air, for starters — that lead to worse health outcomes. When they get sick, they have a harder time both finding a doctor and affording their medical care. In general, they also live with more stress and anxiety than people who make more money, which also has deleterious effects on their health.
“Economic inequality is increasingly linked to disparities in life expectancy across the income distribution, and these disparities seem to be growing over time,” wrote the authors of a 2018 review of relevant research in Health Affairs. Poor health also contributes to lower incomes, creating a feedback loop known as the “health-poverty trap.”
How the US is trying to improve the social determinants of health — slowly
These nonmedical 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 one’s ability to live a healthy life. And they’re also one of the signature failings of the US health system.
Here is another way to think about how American health care has been misaligned on this issue, from a 2016 New England Journal of Medicine article:
For decades, experts have described a profound imbalance between public funding of acute medical care and investments in upstream social and environmental determinants of health. By some estimates, more than 95% of the trillion dollars spent on health care in the United States each year funds direct medical services, even though 60% of preventable deaths are rooted in modifiable behaviors and exposures that occur in the community.
This is also part of the US health system that’s too often ignored in the health care policy debate. Social determinants are a bedrock of public health theory, but US politicians don’t always talk about food assistance, financial aid, or other welfare programs as part of their strategy to improve the nation’s health. Even so, the two spheres are inextricably linked.
“We have decades, if not centuries, of evidence proving to us that social determinants are really important in influencing health,” Amanda Brewster, a professor at the University of California Berkeley who has studied the relationship between the two, told me.
That knowledge is starting to permeate more of the policy debate, as the health care industry itself signals 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 health care sector in grappling with what to do about social determinants,” Brewster said, citing the shift to more value-based payment for health care as “one thing that’s helped encourage creativity in health care providers and organizations about the range of ways they might improve people’s health.”
One challenge is that, following decades of underinvesting in social supports, the US does not have many internal models of success upon which to build. Barring sudden adoption of a Scandinavian-style social safety net, America must figure out its own strategy for improving 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 do have unique traits — strong individualism, fewer expectations that the government will help with these problems, more racial diversity, increased political polarization — that pose a challenge to turning the tide on 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,” Bradley said. “But how to scale it up across a country this diverse and with these racial divides, that’s where we fall down.”
It’s also a resource problem. Because so much money is already being sunk into medical care, it’s more difficult to muster up the finances for new interventions that would target the social determinants of health.
Even when the federal government has tried to invest more in those kinds of programs, the investment is usually small. The Affordable Care Act established a program called Accountable Health Communities, intended to fund pilot projects that would connect at-risk patients with more social supports. An early evaluation did find a modest reduction in hospital emergency-room visits, but it also concluded that the vast majority of participants did not last an entire year in the program, with case managers citing difficulty keeping in touch with enrollees.
It was also arguably a much smaller program than was necessary. The AHC initiative was funded with about $157 million over five years. Brewster pointed out to me that under a state-level project in California working toward the same goal, a single county received about $200 million.
The California project, the Whole Person Care Pilot program, was established in 2017 through Medicaid and seeded with $3 billion for a five-year effort. It’s too early to say how much it’s actually improving health, but Brewster explained how it works to illustrate what better coordination between the social services and medical spheres might look like.
In Contra Costa County, for example, the county integrated different data systems to identify which patients have complex needs and are at the highest risk of eventually developing serious medical problems. 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 set up mental health support — in other words, establish a comprehensive care plan that goes beyond medical services. Patients can also receive a cellphone, free of charge, to make it easier for them to stay connected with the program.
“It’s not just seeing their primary care physician, but this whole portfolio of stuff we know is important for health,” Brewster said. “It really blurs the borders of these care systems.”
At the start of the Covid-19 pandemic, the county recalibrated its data systems to identify people at higher risk for severe illness from the novel coronavirus. Case managers then reached out to set up those people with food deliveries and other services that would help them shelter in place and reduce their risk of infection.
Brewster stressed we should have realistic expectations about what programs that target social determinants of health can accomplish. They may not drive down aggregate health spending, for example; in the US, the problem is not that people use more medical services but that the prices for those services are higher. The federal AHC program had a relatively modest effect, which may reflect the fact that the program was “too little, too late” for people who already had complex medical needs.
“These programs aren’t drugs,” she said. “These are complex interventions. They might work well in some places and less well in others.”
But in terms of improving people’s actual health outcomes and long-term quality of life, this is one of the more promising frontiers in US health policy.