QJM Advance Access published October 24, 2016
American health care paradox - high spending on health care and poor health
Elizabeth H. Bradley, PhD, Yale School of Public Health Heather Sipsma, PhD, University of Chicago
© The Author 2016. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: [email protected]
Downloaded from by guest on November 4, 2016
Lauren A. Taylor, MPH, MDiv, Harvard Business School
Abstract Background For decades, U.S. taxpayers have been lamenting the high cost of health care. Since the mid1980s, Americans have had double-digit spending on health care. Despite this investment, Americans are less healthy than their European and Scandinavian counterparts across an array of health measures. Aim We sought to explore how inadequate attention to the social, behavioral, and environmental determinants of health may contribute to the American health care paradox of high health care
Design Mixed methods Methods We report previous findings related from a 10-year analysis of national-level health and social service spending and health outcome data from the Organisation of Economic and Cooperation and Development (OECD). We also put forth case studies representing different socioeconomic strata to illustrate the relationship between health care and social service spending and health. Results Although the U.S. spending more of its GDP on health care than any other country, it is not a high spender when one sums spending on both health care and social services. The U.S. however has the lowest ratio of our social service spending to health care spending in the OECD, and countries with lower ratios on average have worse health outcomes. Cases from
Downloaded from by guest on November 4, 2016
spending and poor health outcomes.
diverse socioeconomic strata demonstrate how limited attention to the social determinants of health can result in extremely high health care costs and poor health outcomes. Conclusions Greater investment in addressing the social, behavioral, and environmental determinants of health may foster better health without accelerating health care costs in America.
Downloaded from by guest on November 4, 2016
For decades, U.S. taxpayers have been lamenting the high cost of health care. Since the mid-1980s, Americans have had double-digit spending on health care with an estimated 20% of our gross domestic product (GDP) devoted to health care by 2020. This is four times more than we spend on public education, five times more than we spend on military, and twenty times more than we spend on public housing. The sum is particularly remarkable in contrast to commensurate expenditures among peer industrialized countries of Western Europe and Scandinavia, where the average spending on health care is about 11% of their GDP. As many readers are likely now aware, the outcomes side of the equation is even
healthy than their European and Scandinavian counterparts across an array of measures. Americans have lower life expectancy and higher rates of infant mortality, low birth weight, injuries and homicides, adolescent pregnancy and sexually transmitted diseases, HIV/AIDS, drug-related deaths, obesity, diabetes, heart disease, chronic lung disease, and disability than people in other industrialized countries.1 In an effort to maintain their belief that the United States has the best health care system in the world, some Americans find it tempting to comfort themselves by assuming the disparity is related to racial and economic inequality in the U.S. Nevertheless, available data indicate that Americans who are white, insured, collegeeducated, and upper income have poorer health than their counterparts in other industrialized countries.1 There appears to be something uniquely American about spending more on health care and getting less health.
Downloaded from by guest on November 4, 2016
more troubling. Despite the U.S.’ enormous investment for decades, Americans are less
The American health care paradox – the existence of high spending on health care and poor health – can be resolved when we step back to consider what it is that produces a healthy population. As scholars, policy makers, and practitioners steeped in the social determinants of health literature will attest, the larger share of health is attributable to social, environmental, and behavioral factors than to genetics or health care. The academic literature2-4 is unequivocal about the importance of what is referred to as the “social determinants of health,” such as housing, education, income, occupation, environmental contacts, lifestyle, and other similar exposures. Hence, if we want to more fully understand how industrialized nations invest in creating
influence these factors, rather than focusing solely just what countries spend on health care. Such analysis, using data from the 2011, produces a new insight into the American health care paradox. We abstracted expenditure data for countries in the Organisation for Economic Cooperation and Development (OECD; available at http://stats.oecd.org; accessed October 1,
2015) on health care and social services. Health care spending included public (variable name: HF1) and private spending (HF2) across all health care providers (HPTOT) and an array of functions, including current expenditures on health care (all functions; HCTOT), capital formation of health care providers (HCR1), education and training of health personnel (HCR2), research and development in health (HCR3), and social services of long-term care (HCR61). Social services spending included public and mandatory private spending (10_20) both in cash and in kind (0) across all types of programs (0) and branches (90), including spending on old-age pensions and support services for older adults, survivors benefits, disability and sickness cash
Downloaded from by guest on November 4, 2016
a healthy population, we ought to be also examining what these countries spend on services to
benefits, family support, employment programs (e.g., public employment services and employment training), unemployment benefits, housing support (e.g., rent subsidies) and other social policy areas. If we sum countries’ spending on both health care and social services, the United States is no longer the high spender; in fact, we appear near the middle of the pack (Figure 1). Furthermore, the ratio of our social service spending to health care spending is the lowest of all countries in the OECD. From 2000-2011, for every dollar the United States spent on health care, the country spent another $1.00 on social services, whereas across the OECD, for every dollar spent on health care, countries spend an additional $2.50 on social services (Figure 2).
expenditure data from 2009 and mixed-effects regression models, we find countries with higher ratios of social-to-health care spending have significantly higher life expectancy and lower infant mortality after adjusting for health expenditures and GDP.5, 6 In this analysis, social services expenditures included public and private spending on old-age pension and support services for older adults, survivors benefits, disability and sickness cash benefits, family supports, employment programs (e.g., public employment services and employment training, unemployment benefits, housing and rent subsidies), and other social services that exclude health expenditures. Heath expenditures included public and private spending on curative care, rehabilitative care, long-term care, laboratory and diagnostic services, outpatient and preventive care, and public health services. Similar findings are being reported in analyses using state-level data across the United States.7
Downloaded from by guest on November 4, 2016
But do these spending choices matter? It turns out they do. Using health and social
Despite this evidence, the work of changing the national spending patterns faces multiple practical and political challenges, particularly if the underinvestment in social services is viewed narrowly as an issue of “the poor.” Of course, people with low-income face elevated risks of poor housing, unemployment or underemployment, poor nutrition, and unsafe neighborhoods all of which endanger health. Additionally, many, although not all, publiclyfunded social services target people based on poverty or limited income. Nevertheless, critical to propelling national shifts in how we invest in health will be the recognition that the social determinants of health are relevant and active in all human lives, not just marginalized groups. One’s housing, job, nutrition, neighborhood, and larger social context is fundamental to one’s
medical care in the world. The vignettes that follow are true stories (although names and places have been changed for anonymity) that show the breadth of influence of the social determinants of health. The first resembles what health care practitioners sometimes refer to as “high cost utilizers” – individuals living in a neighborhood overrun by drugs, crime, and poverty with multiple risk factors for ill health, who frequent expensive emergency rooms for both emergency and primary care. The second case, in contrast, depicts a vibrant, welleducated, wealthy man whose demise and enormous health care expenses are shaped by employment, housing, and social factors. The last story details a middle-income, older adult with extreme health care costs and poor health unrelated to her physical condition but rather resulting from her social context. These predicaments illustrate a range of cases in which social, behavioral and environmental interventions may have improved health and offset health care costs far more than would added medications and physician visits.
Downloaded from by guest on November 4, 2016
health, although these are often overlooked by people with easy access to some of the finest
********** Case #1: The urban landscape Dwane grew up in an inner city. His father died of AIDS when Dwane was 7 years old. His mother had 9 other children and only temporary work outside the home. The house was big enough but falling apart, with a cracked cement yard. Dwane was the third eldest, but after his older siblings moved out of the house, Dwane had become the most useful child for bringing in some extra cash. He suffered from asthma and had been husky since he could remember. At
his brothers. He was paid fairly well and gave the money to his mother, who was happy to have some extra change to make ends meet. Eighteen months later, the drug dealer in the area promoted Dwane to “look out” status. At 11 years old, he did his first “hand-to-hand” exchange, physically meeting the buyer to sell the drugs directly. His older brothers told Dwane he should have waited until his 12th birthday to do hand-to-hands, and as punishment, they physically assaulted him. When he was 13 years old, one of his brothers gave him his first bundle of crack, and Dwane sold it in 2 hours. His mother used the money he brought in to buy the family new clothes and put more food on the table. Dwane did not care much about school, but he felt good about his work, especially when people complimented him by likening him to his father, a successful drug dealer. In Dwane’s view, he was doing the right thing for his family. Most of what Dwane’s family ate was fast food: KFC, McDonalds, and his favorite – Popeyes. None of his siblings went to school regularly, and when they did, they had few books
Downloaded from by guest on November 4, 2016
the age of 9 years, he learned how to cut cocaine in his palm and transport drugs on behalf of
and mostly ignored the teachers. After school, there was little to do, few parents at home, and easy access to firearms in the neighborhood. His rite of passage (as it was called in the neighborhood), at 14 years old, was to intimidate someone older with guns. Dwane knew he did not need to shoot anyone - just show he could give them a scare. He targeted his 28-year old cousin, who was just out of prison after serving a 10-year sentence for manslaughter. His cousin, feeling disrespected by a 14-year old, beat Dwane to a pulp in front of his brothers, his friends, and even his mother, who watched, but said nothing. No one intervened. Afterwards, Dwane ran to get two guns from the house to kill his cousin. His mother stopped him and locked him in his room until the next morning. He remembers her scolding him, “You need to
neighborhood with an abundance of drugs, little affordable, fresh food, and no stable home or family on which to rely. Dwane’s response to the chaos in his life was to begin using the drugs he sold. At the age of 16, with limited literacy and no upper-level math skills, he dropped out of school. He could not get a driver’s license because he had never paid a bicycle ticket. Without a driver’s license, he is ineligible for most job training programs. He found ways to make money in the drug trade despite having been shot twice before his 17th birthday. Now 25 years old, his drug habit continues, and his asthma has worsened. Dwane is busy with a carousel of part-time jobs, but feels depressed about the neighborhood and the friends who have died. His future promises only sporadic employment, poor housing, and shortened life expectancy, and most likely high medical costs related to potential illnesses at which he is now at high risk including HIV, chronic pulmonary disease, obesity, and clinical depression.
Downloaded from by guest on November 4, 2016
grow up, young man.” Dwane was growing up but in violent and economically deprived
Case #2 Down on his luck Barry is a 56-year old, heavy-set man with a hearty laugh. Hailing from an upper-middle class family of European descent, Barry attended a prep school in New Jersey before attending the University of Pennsylvania, where he earned his undergraduate degree in business and economics. Graduating with a grade point average of 3.4, Barry landed an entry-level position in sales with IBM. After three years, his bosses viewed him to be on the fast track to success and suggested he get an MBA, which he went on to complete at the Harvard Business School.
Johnson and later on Wall Street for a financial consulting firm, where he helped companies develop business strategies and design markets globally. In midlife, Barry grew restless. The extensive global travel required by his job grew burdensome; the lights of Hong Kong, pubs of London, and noise of New York began to lose their thrill. Barry begun to struggle uncharacteristically with feeling that he had lost his sense of direction and his passion. Worried about his wife, who was diagnosed at this time with thyroid cancer also made him recalibrate his time on the road. He started to spend more time browsing the Web and fantasizing about alternative careers, but nothing held his interest. Always heavy but never obese, Barry started to gain weight rapidly. In one 12-month stretch, he put on 50 pounds, stopped being able to wear the business suits needed for his professional roles, and became chronically exhausted.
Downloaded from by guest on November 4, 2016
He then followed his passion for business by accepting positions in marketing for Johnson &
Still flush with cash from more than 20 years as a top business executive, Barry decided to try his hand at entrepreneurship, thinking it would bring back his passion for business. With $1 million he had accrued, Barry invested in various ventures over a decade, but none were successful. Over time, he sunk more and more savings into what became failed start-up companies and schemes. He sold his house during this time as he and his wife moved to be closer to the investment properties and businesses. The first project fell through due to his business partner’s illegal tax withholding activity; the second was a little better but never came to fruition, and the third ended tragically when his partner and close friend died of advanced cancer with less than 6 weeks’ notice. His fourth and last business project failed in the recession
As this business closed its doors in the same year it opened, Barry found himself financially and emotionally depleted. He was without a permanent home, unable to pay rent, and feeling like a failure. His friend’s suicide hurt and depressed him, but did not surprise him; by then, Barry had contemplated suicide several times himself. Barry is now morbidly obese at 6 feet tall and 320 pounds, a binge eater, and prediabetic. He is uninsured and lives in temporary housing. He suffers from frequent leg cramps, periodic chest pain and despondence and is in the early stages of developing some of the costliest diseases to treat, including clinical depression, heart disease, and diabetes. He and his wife, whose thyroid cancer is in remission, are living one day at a time without insurance and facing medical bills they cannot afford. Barry says he is trying to figure out how to get bariatric surgery, thinking it might help him lose weight, but he has difficulty finding doctors who will
Downloaded from by guest on November 4, 2016
following the crash of 2008, when the primary investor, a long-time friend, committed suicide.
take his case. Barry and his wife each have multiple prescriptions that place additional strain on household finances, and they are not sure how they will make ends meet in the future.
Case #3: Aging alone Martha is a 72 year-old Irish-American woman with high blood pressure and the beginnings of dementia. She worked in the business office of an insurance company for four decades and was married for 45 years. She never had children and was the primary caretaker for both her parents. Twenty years ago, she lost both her parents and her husband within a
developed severe anxiety in the new home. Her brother, who was 10 years older than Martha, struggled to take care of her after she started to develop more symptomatic forms of dementia. Neither Martha nor her brother had a driver’s license, but in the past they lived close enough to the center of town to pick up staples from the corner store. As Martha aged, she became less steady on her feet. Money was tight, and the food the two siblings bought was increasingly boxed or canned. Because Martha is anxious, she frequently feels something is wrong with her health. When her anxiety turns to panic, she calls an ambulance to take her to the emergency room. In one year living with her brother, she made 26 such calls; Medicare reimbursed the hospital approximately $1,300 per emergency room visit, and Martha paid about $650 out of her pocket for each ambulance trip. Each time, the physicians found nothing wrong and discharged her, usually the same day, or sometimes the next day running some diagnostic tests. Once, the
Downloaded from by guest on November 4, 2016
two-year time span. At that time, Martha moved in with her older brother at his suggestion, but
hospital social worker took special interest in Martha and sent her to a residential psychiatric facility, where she stayed for 30 days and was treated with shock therapy to no avail, leaving her with substantial medical expenses. When Martha was discharged, she returned to her brother’s house, again grew anxious, and resumed her pattern of biweekly visits to the emergency room. Between the emergency room and residential psychiatric care, Martha had racked up medical expenses of nearly $60,000 for the year with virtually no improvement to her health. ********** A major conclusion from these stories is that the social determinants of health are
examples are intended to challenge the more typical narrative in American health policy regarding who stands to benefit from a greater emphasis on the social determinants of health. Too often, the assumption that policy attention directed towards non-medical interventions stands to benefit only “the poor” goes unchecked. In actuality, the non-medical influences on health are pertinent regardless of income; however, because income allocations toward housing, schools, food, physical activity and the like are made privately by wealthier Americans, the policy dialogue regarding the prudence of these investments is limited. Only when the beneficiaries are people with low income - for whom public dollars are spent to ensure adequate housing, nutrition, and education do these choices become the subject of public debate and engagement. This leaves many with the wrong impression that the social determinants of health are a challenge unique to “the poor” when in fact it is more veracious to say that the shared costs
Downloaded from by guest on November 4, 2016
essential to the lives of Americans from a range of backgrounds and income levels. The
associated with the social determinants of health are more easily calculated for people on public insurance. Exacerbating this bias in the literature is a longstanding tradition of scapegoating “the poor” for a variety of social challenges, fueled by the cultural myth that to be poor is to be lazy, morally corrupt or unintelligent. This belief has been empirically found to be incorrect time and again, but nonetheless persists. In order for substantial investments of time or resources in the social determinants of health in the United States to be made, we must recognize the flaws inherent in these lines of thinking. As the cases outlined above have demonstrated, the health of all Americans are subject to social determinants. Whether it is social isolation of a wealthy, White older American
drive costs. Thus, if we wish to improve health and contain costs on a national scale, all Americans should remain squarely without our purview as potential beneficiaries of intervention.
Downloaded from by guest on November 4, 2016
or homelessness in an immigrant youth, negative social conditions can both damage health and
References Woolf SH, Aron L, eds. US Health in International Perspective: Shorter Lives, Poorer Health. Washington DC, National Academies Press, 2013.
2.
McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff (Millwood) 2002; 21(2):78-93.
3.
Marmot MG, Bell R. Action on health disparities in the United States: commission on social determinants of health. JAMA 2009; 301(11):1169-71.
4.
Wilkinson RG, Marmot M. Social determinants of health: the solid facts: World Health Organization; 2003.
5.
Bradley EH, Elkins BR, Herrin J, Elbel B. Health and social services expenditures: associations with health outcomes. BMJ Qual Saf 2011; 20(10):826-31.
6.
Bradley EH, Taylor LA. The American Health Care Paradox : Why Spending More is Getting us Less. First ed. New York: Public Affairs; 2013.
7.
Bradley EH, Canavan M, Rogan E, Talbert-Slagle K, Ndumele CD, Taylor L, et al. Variations in health outcomes across the United States: the roles of social service, public health, and health care spending. Forthcoming.
Downloaded from by guest on November 4, 2016
1.
Figure Legend Figure 1. Total expenditures as a percentage of GDP, 2011
Figure 2. Ratio of social services spending to health care spending from 2000 to 2011
Downloaded from by guest on November 4, 2016
Downloaded from by guest on November 4, 2016
Downloaded from by guest on November 4, 2016
American health care paradox - high spending on health care and poor health
Elizabeth H. Bradley, PhD, Yale School of Public Health Heather Sipsma, PhD, University of Chicago
© The Author 2016. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: [email protected]
Downloaded from by guest on November 4, 2016
Lauren A. Taylor, MPH, MDiv, Harvard Business School
Abstract Background For decades, U.S. taxpayers have been lamenting the high cost of health care. Since the mid1980s, Americans have had double-digit spending on health care. Despite this investment, Americans are less healthy than their European and Scandinavian counterparts across an array of health measures. Aim We sought to explore how inadequate attention to the social, behavioral, and environmental determinants of health may contribute to the American health care paradox of high health care
Design Mixed methods Methods We report previous findings related from a 10-year analysis of national-level health and social service spending and health outcome data from the Organisation of Economic and Cooperation and Development (OECD). We also put forth case studies representing different socioeconomic strata to illustrate the relationship between health care and social service spending and health. Results Although the U.S. spending more of its GDP on health care than any other country, it is not a high spender when one sums spending on both health care and social services. The U.S. however has the lowest ratio of our social service spending to health care spending in the OECD, and countries with lower ratios on average have worse health outcomes. Cases from
Downloaded from by guest on November 4, 2016
spending and poor health outcomes.
diverse socioeconomic strata demonstrate how limited attention to the social determinants of health can result in extremely high health care costs and poor health outcomes. Conclusions Greater investment in addressing the social, behavioral, and environmental determinants of health may foster better health without accelerating health care costs in America.
Downloaded from by guest on November 4, 2016
For decades, U.S. taxpayers have been lamenting the high cost of health care. Since the mid-1980s, Americans have had double-digit spending on health care with an estimated 20% of our gross domestic product (GDP) devoted to health care by 2020. This is four times more than we spend on public education, five times more than we spend on military, and twenty times more than we spend on public housing. The sum is particularly remarkable in contrast to commensurate expenditures among peer industrialized countries of Western Europe and Scandinavia, where the average spending on health care is about 11% of their GDP. As many readers are likely now aware, the outcomes side of the equation is even
healthy than their European and Scandinavian counterparts across an array of measures. Americans have lower life expectancy and higher rates of infant mortality, low birth weight, injuries and homicides, adolescent pregnancy and sexually transmitted diseases, HIV/AIDS, drug-related deaths, obesity, diabetes, heart disease, chronic lung disease, and disability than people in other industrialized countries.1 In an effort to maintain their belief that the United States has the best health care system in the world, some Americans find it tempting to comfort themselves by assuming the disparity is related to racial and economic inequality in the U.S. Nevertheless, available data indicate that Americans who are white, insured, collegeeducated, and upper income have poorer health than their counterparts in other industrialized countries.1 There appears to be something uniquely American about spending more on health care and getting less health.
Downloaded from by guest on November 4, 2016
more troubling. Despite the U.S.’ enormous investment for decades, Americans are less
The American health care paradox – the existence of high spending on health care and poor health – can be resolved when we step back to consider what it is that produces a healthy population. As scholars, policy makers, and practitioners steeped in the social determinants of health literature will attest, the larger share of health is attributable to social, environmental, and behavioral factors than to genetics or health care. The academic literature2-4 is unequivocal about the importance of what is referred to as the “social determinants of health,” such as housing, education, income, occupation, environmental contacts, lifestyle, and other similar exposures. Hence, if we want to more fully understand how industrialized nations invest in creating
influence these factors, rather than focusing solely just what countries spend on health care. Such analysis, using data from the 2011, produces a new insight into the American health care paradox. We abstracted expenditure data for countries in the Organisation for Economic Cooperation and Development (OECD; available at http://stats.oecd.org; accessed October 1,
2015) on health care and social services. Health care spending included public (variable name: HF1) and private spending (HF2) across all health care providers (HPTOT) and an array of functions, including current expenditures on health care (all functions; HCTOT), capital formation of health care providers (HCR1), education and training of health personnel (HCR2), research and development in health (HCR3), and social services of long-term care (HCR61). Social services spending included public and mandatory private spending (10_20) both in cash and in kind (0) across all types of programs (0) and branches (90), including spending on old-age pensions and support services for older adults, survivors benefits, disability and sickness cash
Downloaded from by guest on November 4, 2016
a healthy population, we ought to be also examining what these countries spend on services to
benefits, family support, employment programs (e.g., public employment services and employment training), unemployment benefits, housing support (e.g., rent subsidies) and other social policy areas. If we sum countries’ spending on both health care and social services, the United States is no longer the high spender; in fact, we appear near the middle of the pack (Figure 1). Furthermore, the ratio of our social service spending to health care spending is the lowest of all countries in the OECD. From 2000-2011, for every dollar the United States spent on health care, the country spent another $1.00 on social services, whereas across the OECD, for every dollar spent on health care, countries spend an additional $2.50 on social services (Figure 2).
expenditure data from 2009 and mixed-effects regression models, we find countries with higher ratios of social-to-health care spending have significantly higher life expectancy and lower infant mortality after adjusting for health expenditures and GDP.5, 6 In this analysis, social services expenditures included public and private spending on old-age pension and support services for older adults, survivors benefits, disability and sickness cash benefits, family supports, employment programs (e.g., public employment services and employment training, unemployment benefits, housing and rent subsidies), and other social services that exclude health expenditures. Heath expenditures included public and private spending on curative care, rehabilitative care, long-term care, laboratory and diagnostic services, outpatient and preventive care, and public health services. Similar findings are being reported in analyses using state-level data across the United States.7
Downloaded from by guest on November 4, 2016
But do these spending choices matter? It turns out they do. Using health and social
Despite this evidence, the work of changing the national spending patterns faces multiple practical and political challenges, particularly if the underinvestment in social services is viewed narrowly as an issue of “the poor.” Of course, people with low-income face elevated risks of poor housing, unemployment or underemployment, poor nutrition, and unsafe neighborhoods all of which endanger health. Additionally, many, although not all, publiclyfunded social services target people based on poverty or limited income. Nevertheless, critical to propelling national shifts in how we invest in health will be the recognition that the social determinants of health are relevant and active in all human lives, not just marginalized groups. One’s housing, job, nutrition, neighborhood, and larger social context is fundamental to one’s
medical care in the world. The vignettes that follow are true stories (although names and places have been changed for anonymity) that show the breadth of influence of the social determinants of health. The first resembles what health care practitioners sometimes refer to as “high cost utilizers” – individuals living in a neighborhood overrun by drugs, crime, and poverty with multiple risk factors for ill health, who frequent expensive emergency rooms for both emergency and primary care. The second case, in contrast, depicts a vibrant, welleducated, wealthy man whose demise and enormous health care expenses are shaped by employment, housing, and social factors. The last story details a middle-income, older adult with extreme health care costs and poor health unrelated to her physical condition but rather resulting from her social context. These predicaments illustrate a range of cases in which social, behavioral and environmental interventions may have improved health and offset health care costs far more than would added medications and physician visits.
Downloaded from by guest on November 4, 2016
health, although these are often overlooked by people with easy access to some of the finest
********** Case #1: The urban landscape Dwane grew up in an inner city. His father died of AIDS when Dwane was 7 years old. His mother had 9 other children and only temporary work outside the home. The house was big enough but falling apart, with a cracked cement yard. Dwane was the third eldest, but after his older siblings moved out of the house, Dwane had become the most useful child for bringing in some extra cash. He suffered from asthma and had been husky since he could remember. At
his brothers. He was paid fairly well and gave the money to his mother, who was happy to have some extra change to make ends meet. Eighteen months later, the drug dealer in the area promoted Dwane to “look out” status. At 11 years old, he did his first “hand-to-hand” exchange, physically meeting the buyer to sell the drugs directly. His older brothers told Dwane he should have waited until his 12th birthday to do hand-to-hands, and as punishment, they physically assaulted him. When he was 13 years old, one of his brothers gave him his first bundle of crack, and Dwane sold it in 2 hours. His mother used the money he brought in to buy the family new clothes and put more food on the table. Dwane did not care much about school, but he felt good about his work, especially when people complimented him by likening him to his father, a successful drug dealer. In Dwane’s view, he was doing the right thing for his family. Most of what Dwane’s family ate was fast food: KFC, McDonalds, and his favorite – Popeyes. None of his siblings went to school regularly, and when they did, they had few books
Downloaded from by guest on November 4, 2016
the age of 9 years, he learned how to cut cocaine in his palm and transport drugs on behalf of
and mostly ignored the teachers. After school, there was little to do, few parents at home, and easy access to firearms in the neighborhood. His rite of passage (as it was called in the neighborhood), at 14 years old, was to intimidate someone older with guns. Dwane knew he did not need to shoot anyone - just show he could give them a scare. He targeted his 28-year old cousin, who was just out of prison after serving a 10-year sentence for manslaughter. His cousin, feeling disrespected by a 14-year old, beat Dwane to a pulp in front of his brothers, his friends, and even his mother, who watched, but said nothing. No one intervened. Afterwards, Dwane ran to get two guns from the house to kill his cousin. His mother stopped him and locked him in his room until the next morning. He remembers her scolding him, “You need to
neighborhood with an abundance of drugs, little affordable, fresh food, and no stable home or family on which to rely. Dwane’s response to the chaos in his life was to begin using the drugs he sold. At the age of 16, with limited literacy and no upper-level math skills, he dropped out of school. He could not get a driver’s license because he had never paid a bicycle ticket. Without a driver’s license, he is ineligible for most job training programs. He found ways to make money in the drug trade despite having been shot twice before his 17th birthday. Now 25 years old, his drug habit continues, and his asthma has worsened. Dwane is busy with a carousel of part-time jobs, but feels depressed about the neighborhood and the friends who have died. His future promises only sporadic employment, poor housing, and shortened life expectancy, and most likely high medical costs related to potential illnesses at which he is now at high risk including HIV, chronic pulmonary disease, obesity, and clinical depression.
Downloaded from by guest on November 4, 2016
grow up, young man.” Dwane was growing up but in violent and economically deprived
Case #2 Down on his luck Barry is a 56-year old, heavy-set man with a hearty laugh. Hailing from an upper-middle class family of European descent, Barry attended a prep school in New Jersey before attending the University of Pennsylvania, where he earned his undergraduate degree in business and economics. Graduating with a grade point average of 3.4, Barry landed an entry-level position in sales with IBM. After three years, his bosses viewed him to be on the fast track to success and suggested he get an MBA, which he went on to complete at the Harvard Business School.
Johnson and later on Wall Street for a financial consulting firm, where he helped companies develop business strategies and design markets globally. In midlife, Barry grew restless. The extensive global travel required by his job grew burdensome; the lights of Hong Kong, pubs of London, and noise of New York began to lose their thrill. Barry begun to struggle uncharacteristically with feeling that he had lost his sense of direction and his passion. Worried about his wife, who was diagnosed at this time with thyroid cancer also made him recalibrate his time on the road. He started to spend more time browsing the Web and fantasizing about alternative careers, but nothing held his interest. Always heavy but never obese, Barry started to gain weight rapidly. In one 12-month stretch, he put on 50 pounds, stopped being able to wear the business suits needed for his professional roles, and became chronically exhausted.
Downloaded from by guest on November 4, 2016
He then followed his passion for business by accepting positions in marketing for Johnson &
Still flush with cash from more than 20 years as a top business executive, Barry decided to try his hand at entrepreneurship, thinking it would bring back his passion for business. With $1 million he had accrued, Barry invested in various ventures over a decade, but none were successful. Over time, he sunk more and more savings into what became failed start-up companies and schemes. He sold his house during this time as he and his wife moved to be closer to the investment properties and businesses. The first project fell through due to his business partner’s illegal tax withholding activity; the second was a little better but never came to fruition, and the third ended tragically when his partner and close friend died of advanced cancer with less than 6 weeks’ notice. His fourth and last business project failed in the recession
As this business closed its doors in the same year it opened, Barry found himself financially and emotionally depleted. He was without a permanent home, unable to pay rent, and feeling like a failure. His friend’s suicide hurt and depressed him, but did not surprise him; by then, Barry had contemplated suicide several times himself. Barry is now morbidly obese at 6 feet tall and 320 pounds, a binge eater, and prediabetic. He is uninsured and lives in temporary housing. He suffers from frequent leg cramps, periodic chest pain and despondence and is in the early stages of developing some of the costliest diseases to treat, including clinical depression, heart disease, and diabetes. He and his wife, whose thyroid cancer is in remission, are living one day at a time without insurance and facing medical bills they cannot afford. Barry says he is trying to figure out how to get bariatric surgery, thinking it might help him lose weight, but he has difficulty finding doctors who will
Downloaded from by guest on November 4, 2016
following the crash of 2008, when the primary investor, a long-time friend, committed suicide.
take his case. Barry and his wife each have multiple prescriptions that place additional strain on household finances, and they are not sure how they will make ends meet in the future.
Case #3: Aging alone Martha is a 72 year-old Irish-American woman with high blood pressure and the beginnings of dementia. She worked in the business office of an insurance company for four decades and was married for 45 years. She never had children and was the primary caretaker for both her parents. Twenty years ago, she lost both her parents and her husband within a
developed severe anxiety in the new home. Her brother, who was 10 years older than Martha, struggled to take care of her after she started to develop more symptomatic forms of dementia. Neither Martha nor her brother had a driver’s license, but in the past they lived close enough to the center of town to pick up staples from the corner store. As Martha aged, she became less steady on her feet. Money was tight, and the food the two siblings bought was increasingly boxed or canned. Because Martha is anxious, she frequently feels something is wrong with her health. When her anxiety turns to panic, she calls an ambulance to take her to the emergency room. In one year living with her brother, she made 26 such calls; Medicare reimbursed the hospital approximately $1,300 per emergency room visit, and Martha paid about $650 out of her pocket for each ambulance trip. Each time, the physicians found nothing wrong and discharged her, usually the same day, or sometimes the next day running some diagnostic tests. Once, the
Downloaded from by guest on November 4, 2016
two-year time span. At that time, Martha moved in with her older brother at his suggestion, but
hospital social worker took special interest in Martha and sent her to a residential psychiatric facility, where she stayed for 30 days and was treated with shock therapy to no avail, leaving her with substantial medical expenses. When Martha was discharged, she returned to her brother’s house, again grew anxious, and resumed her pattern of biweekly visits to the emergency room. Between the emergency room and residential psychiatric care, Martha had racked up medical expenses of nearly $60,000 for the year with virtually no improvement to her health. ********** A major conclusion from these stories is that the social determinants of health are
examples are intended to challenge the more typical narrative in American health policy regarding who stands to benefit from a greater emphasis on the social determinants of health. Too often, the assumption that policy attention directed towards non-medical interventions stands to benefit only “the poor” goes unchecked. In actuality, the non-medical influences on health are pertinent regardless of income; however, because income allocations toward housing, schools, food, physical activity and the like are made privately by wealthier Americans, the policy dialogue regarding the prudence of these investments is limited. Only when the beneficiaries are people with low income - for whom public dollars are spent to ensure adequate housing, nutrition, and education do these choices become the subject of public debate and engagement. This leaves many with the wrong impression that the social determinants of health are a challenge unique to “the poor” when in fact it is more veracious to say that the shared costs
Downloaded from by guest on November 4, 2016
essential to the lives of Americans from a range of backgrounds and income levels. The
associated with the social determinants of health are more easily calculated for people on public insurance. Exacerbating this bias in the literature is a longstanding tradition of scapegoating “the poor” for a variety of social challenges, fueled by the cultural myth that to be poor is to be lazy, morally corrupt or unintelligent. This belief has been empirically found to be incorrect time and again, but nonetheless persists. In order for substantial investments of time or resources in the social determinants of health in the United States to be made, we must recognize the flaws inherent in these lines of thinking. As the cases outlined above have demonstrated, the health of all Americans are subject to social determinants. Whether it is social isolation of a wealthy, White older American
drive costs. Thus, if we wish to improve health and contain costs on a national scale, all Americans should remain squarely without our purview as potential beneficiaries of intervention.
Downloaded from by guest on November 4, 2016
or homelessness in an immigrant youth, negative social conditions can both damage health and
References Woolf SH, Aron L, eds. US Health in International Perspective: Shorter Lives, Poorer Health. Washington DC, National Academies Press, 2013.
2.
McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff (Millwood) 2002; 21(2):78-93.
3.
Marmot MG, Bell R. Action on health disparities in the United States: commission on social determinants of health. JAMA 2009; 301(11):1169-71.
4.
Wilkinson RG, Marmot M. Social determinants of health: the solid facts: World Health Organization; 2003.
5.
Bradley EH, Elkins BR, Herrin J, Elbel B. Health and social services expenditures: associations with health outcomes. BMJ Qual Saf 2011; 20(10):826-31.
6.
Bradley EH, Taylor LA. The American Health Care Paradox : Why Spending More is Getting us Less. First ed. New York: Public Affairs; 2013.
7.
Bradley EH, Canavan M, Rogan E, Talbert-Slagle K, Ndumele CD, Taylor L, et al. Variations in health outcomes across the United States: the roles of social service, public health, and health care spending. Forthcoming.
Downloaded from by guest on November 4, 2016
1.
Figure Legend Figure 1. Total expenditures as a percentage of GDP, 2011
Figure 2. Ratio of social services spending to health care spending from 2000 to 2011
Downloaded from by guest on November 4, 2016
Downloaded from by guest on November 4, 2016
Downloaded from by guest on November 4, 2016
