The American Health Care Paradox: Why Spending More is Getting Us Less

by Elizabeth H. Bradley, Lauren A. Taylor

Foreword by Harvey V. Fineberg, President of the Institute of Medicine

For decades, experts have puzzled over why the US spends more on health care but suffers poorer outcomes than other industrialized nations. Now Elizabeth H. Bradley and Lauren A. Taylor marshal extensive research, including a comparative study of health care data from thirty countries, and get to the root of this paradox: We've left out of our tally the most impactful expenditures countries make to improve the health of their populations-investments in social services.

In The American Health Care Paradox , Bradley and Taylor illuminate how narrow definitions of "health care," archaic divisions in the distribution of health and social services, and our allergy to government programs combine to create needless suffering in individual lives, even as health care spending continues to soar. They show us how and why the US health care "system" developed as it did; examine the constraints on, and possibilities for, reform; and profile inspiring new initiatives from around the world.

Offering a unique and clarifying perspective on the problems the Affordable Care Act won't solve, this book also points a new way forward.

Genres: Health Care, Nonfiction, Health, Medicine, Politics, Medical, Economics

274 pages, Kindle Edition

First published January 1, 2013

Reviews

[BookstagramETC · Rating 5 out of 5]

For my Sociology of Health Care class, I assigned my students to read The American Health Care Paradox by Elizabeth Bradley and Lauren Taylor. The book's main thesis is that part of what is broken in our health care system is that, unlike almost every other country, we've separated out our medical and social services into two distinct systems. The social services system is undervalued and underfunded - and the medical system is often addressing problems after the fact that could have been prevented by adequate social supports. Fantastic exploration of a complicated system with nuanced but clear answers. Great read.

Central Question:
“How is it that the United States spends more per capita than any other nation on health care, while Americans fare worse on many measures of health?”

Paradox: That we spend more on health care, but we get less in terms of health outcomes.

Goes through a history of why the social service sector and the health care sector rarely overlap or interact in the United States today.... great timeline on pg. 24 of events in health care and social service sector development.

Universal health insurance first suggested on the national level in the United States in 1932!! First president to call formally for the creation of a federal health insurance fund that would be open to all Americans was TRUMAN!

Chapter 3: They present 4 case studies of people caught up in the “spend more, get less” health care paradox. But these stories are not about health care alone – what non-health care weaknesses in our system do these stories highlight? (pg. 55)
Answer: inadequate SOCIAL supports, environmental and community risks, economic instability; intervention was possible for each of them through low-cost social services such as after-school programs, nutritional support, employment support groups or counseling, adult daycare programs. Could have been prevented from full-blown medical care emergency.

Theme of this chapter: health care sector bears the brunt of an inadequate social service sector (56)

It’s widely acknowledged that the U.S. is at the forefront of innovation in medical research and development and American researchers have pioneered cutting edge medical treatments. But, and this seems to be a core thesis of this book, “By focusing only on health care, innovators overlook potential synergies between health care and social service sectors that, if leveraged, might result in cost-reducing ways to promote health” (pg. 122). What are some examples of intersections between medical and social services (pg. 123)? Can you think of others beyond their examples listed here from your own experiences or those of a family member?
Examples: transportation for older person to appointments, acupuncture for a cancer patient, job placement for accident victims, safe housing for survivors of domestic abuse

Paradox: How could the United States devote so much money to health care and yet rank so poorly relative to other industrialized countries on key indicators of the nation’s health? (pg. 181)
One answer: American spending on social services is far less per capita than that of counterpart countries.

Emphasis of penultimate chapter: health is determined by more than medicine. Health does not mean only medical or health care. We must address non-medical determinants of health such as social, environmental, and behavioral factors to increase health in our population. (pg. 182)

[Justin Murphy · Rating 4 out of 5]

Recommended by my friend Tori Mueller as an entry level overview of American health care. I gifted the book to my older brother, Chris Murphy, who founded an ADHD startup called TalkTwo.

The book successfully gives a digestible background on the health care industry. I agree that as a country we should be pursuing holistic health. However, I am not sure the Scandinavian model is the right solution.

Based on the American Ethos of individualism, hard work, and a constant strive for improvement I don't see, or want us, to become a society of handouts. I believe in what Ben Sasse calls "a life of production." I think in order to solve this government and enterprise must partner to deliver a solution for the everyday American using technology.

Technology is the only way the concept of a medical home can scale. By putting the patient at the center of the health care conversation the medical home delivers holistic health and allows medical professionals to maintain their autonomy. Ultimately cutting costs, creating jobs, and improving the life of the everyday American.

This would require new infrastructure and a robust education system to train the knowledge workers needed to use it. Only government could deliver such sweeping reforms with strong partnerships in enterprise to help execute on them.

If successful I think it would begin a new era of prosperity and a route to unify the nation by providing broad education, opportunity, and shared experiences for the everyday American.

The American Health Care Paradox was an easy read that prompted many interesting discussions. I still have a lot to learn about the industry but this felt like a good start!

[Sunny Yoo · Rating 5 out of 5]

Easy and fun to read without much background knowledge of the topic at hand. This book does an excellent job presenting the business/politic influences that helped develop the healthcare we see today. It also explains how social services and hospital care grew independently and not interdependently like in Scandinavian and other countries who are able to keep medical costs down by spending more on social services. It shows the cultural views and differences of the general American and general Scandinavian countries' citizens.

More money/resources needs to be spent on social services in America to better support patients' non-medical needs and ensure they have the foundation/means to return to normal health. Health includes not only what we can do for them at the hospital but health is also about improving the overall quality of life including social, mental, and spiritual health. Only then can we learn to find stability, a job, and help others.

The book is broad and even points at the flaws/challenges in Scandinavian countries' healthcare and how we must adapt the aspects of the plan that work and resolve issues that don't. The book also does a nice job citing examples from successful and resourceful programs in America. Healthcare's policies/efficiency may be a convoluted issue, but social services and interdependence of different professions is something America needs more of.

There is still hope and room for improvement for all in America.

[Valerie · Rating 3 out of 5]

I read this book as part of my own continuing education program :). I teach a course on Health Policy and Politics, so I try to stay up to date on the current research/literature. The authors of this book compare our health care system (with a specific focus on outcomes and cost) to the system in Scandinavian countries. Scandinavian countries put an equal emphasis on social and health programs, while U.S. puts more effort on providing health care coverage. I found the authors thought-provoking, but also felt that they failed to address some key issues, such as diversity in the U.S. as compared to Scandinavian countries.

[katen moore · Rating 5 out of 5]

Very readable, not dumbed down, serious discussion of US health care. Qualitative analysis wonderful way to look at this comparison to other country's solutions

[Megan Lee · Rating 3 out of 5]

Dear Jillian and Joaquin,

I really liked more of the personal accounts of patient stories but got a little slow towards the end🥴🥴 also liked though the organizations that have helped fix healthcare slay!!

Cheers,
Megan

[Benjamin · Rating 3 out of 5]

The first chapter is the important part

I wish it was written a couple years post ACA with those conclusions

[Blake Ayers · Rating 5 out of 5]

Social services have more of an impact on the health of populations than hospitals....but don't reap the same profit

[Austin Wu · Rating 3 out of 5]

Three stars is a bit harsh, but since Goodreads does not have half stars the decision was made to round down rather than up.

I had previously written a review of this book for a seminar in health policy in the fall of 2020, so here it is as follows --

Discussion of healthcare reform in the United States can seem like a scene out of Groundhog Day at times, with the same set of facts continually presented around the same narrative – we spend the most money per person in the world, emphasize treatment over prevention, yada yada yada, mediocre outcomes and wide inequalities – and so on. Elizabeth Bradley and Lauren Taylor offer a quietly radical proposition – that the United States is not, in fact, the world leader in health-related spending, if expenditures on social services such as public housing, maternal and child care, and education are also taken into account. If healthcare and social spending are combined, the United States actually spends much less than many other developed countries, and receives relatively mediocre outcomes accordingly.

What sets Americans apart from the rest, posit Bradley and Taylor, is the proportions of that spending – a disproportionate amount towards medical care, and much less towards social services. As a result, the American medical system tends to ignore social determinants of health such as hunger, poverty, housing, and community ties, instead preferring to let problems with peoples’ health progress to the point where the only route of recourse left is expensive treatment and medication. After such procedures, little follow-up is done, leaving the cycle to repeat itself.
Bradley and Taylor’s account is also bolstered by informant interviews of stakeholders from all segments of the medical sector, including administrators, nurses, physicians, and public servants. Regardless of their background, all are in broad agreement on the need to increase societal focus on the upstream factors of overall well-being, and the necessity for people to achieve economic and social stability before they could adequately follow through with complex medical procedures.

Uniquely for an American narrative, Bradley and Taylor explore the ways in which the spectre of anticommunist rhetoric – more often based in perceived, rather than actual threats – has affected public discourse surrounding both healthcare and social services in the United States over the past century. In both cases, an apprehension of public authority and a culture prizing an aspirational notion of individual hardiness has set up decentralized, fragmented systems largely operated by a patchwork of private providers which seek to discriminate between an un-needing privileged, a hard-working group of ‘worthy’ poor deserving of pity, and a third group of outcasts and misfits whose chances for assistance have been undone by their own individual failures. From the findings of Franklin Roosevelt’s 1932 Committee on the Costs of Medical Care to the restrictions placed on the neighborhood health centers of the 1960s and even the health management organizations of the 1970s and 80s, efforts at focusing on population health fell time and time again to the calling card of ‘socialism’. It is with this understanding of the past that allows the authors to look beyond the Overton window of contemporary discussions of healthcare, and to examine routes of recourse both domestically and abroad.

Perhaps unsurprisingly, preparation for the book took Bradley and Taylor to the social democracies of Denmark, Norway, and Sweden, where universal, publicly financed healthcare and welfare programs have produced stellar health and quality of life outcomes while reducing inequality. The author’ findings attributed Scandinavian values tending towards universalism as a product of the trauma of the Second World War – born from the destruction and isolation of their countries through conflict, resistance to the Nazi occupiers, and the task of reconstruction afterwards. Hopefully, Americans will need not bear witness to such a cataclysmic event to be spurred into action. But with a global pandemic ongoing right now and the consequences of unmitigated climate change close on the horizon, such wishful thinking might have run its course. While the saying “never let a serious crisis go to waste” has been popularized through political usage, it actually has its roots in an article from a medical journal – on the utility of using medical crises as an inflection point from which to make improvements to a patient’s way of life.

There are some minor errors in this book which detract from its overall credibility. For example, the American Medical Association’s anticommunist framing of their opposition to the findings of the 1932 Committee on the Costs of Medical Care are described as “cold war terms” when the conditions for tensions between the United States and Soviet Union would not exist for another 15 years, and it is claimed that the Korean War ended in 1961 when in fact active hostilities concluded in 1953. However, it goes without saying that Bradley and Taylor are researchers of health and healthcare first, not military history.

A non-inconsiderable amount of time has passed since the first edition of this book was released in 2013. Since then, a series of major events have taken place in the field of health in the United States, including implementation of the Affordable Care Act (ACA), concerted efforts at repeal by the administration of Donald Trump, and increased political pressure from the left for healthcare reform much more expansive than the ACA. Events from this year added growing recognition of racism as a public health crisis in the United States following wide racially-based disparities in impacts of the COVID-19 pandemic as well as egregious acts of police violence directed at Black Americans to the list of concerns. While some of their attempts to anticipate the future – such as their apprehension about the long-term viability of accountable care organizations (ACOs) in improving population health, have proven to be warranted, other decisions have not.
Perhaps in their efforts to ensure the book does not “advocate on behalf of social justice” – a decision likely made to stymie accusations of bias – the content of the book is fairly colorblind, even though the topic at hand is certainly not. Racial inequality only receives one mention in the entire book, and the case narratives mentioned in its introductory segments do not make any explicit reference to minority ethnic or racial groups. Such thinking, while justifiable, seems out of place in the current year.

Bradley and Taylor make no claim to any particular political affiliation, but their book would be worth reviewing for any advocate of ‘Medicare for All’. The overlap between supporters of ‘Medicare for All’ and supporters of other items such as a Green New Deal and expanded public housing is considerable, if not nearly synonymous. For all of its ambition, ‘Medicare for All’ still falls into the same trap of isolating the business of health and wellness into the domain of the healthcare sector, while facing head-on the incredibly entrenched power and influence of the medical-industrial complex. However, Bradley and Taylor’s call for increased investment into social welfare spending would fit in with many of the ancillary goals of Congresswoman Alexandria Ocasio-Cortez’s (D-NY) Green New Deal for example. Her 2019 resolution contains many of the items mentioned by the authors in their book, including increased investment in public transportation, affordable housing and housing rehabilitation, as well as more generous leave and vacation policies for workers.

For the next generation of progressive reformers, the answer may not lie in an assault on the mass of clinics, hospitals, and insurers, but rather in expanding the United States’ woefully inadequate social welfare services – and as the authors crucially note, not just for the poor either. The American Health Care Paradox provides an accessible, yet comprehensive primer into the intersection of healthcare, employment, the environment, class, and the everything else that collectively determines one’s overall well-being, while also leaving a trailhead for potential paths to a better future.

[Tony Segreto · Rating 4 out of 5]

The American Health Care Paradox presents a very eloquent, easy to read, and informative narrative on health care in the United States. As the title suggests, the authors focus on the paradox of the health care system in the United States for its high costs relative to the quality of care received by its citizens. The book is separated into three sections: the first discusses the origins of the health care system in the United States and how it has developed and changed since the 1800s with Civil War hospitals to the Great Society era of the 1960s; the second compares the healthcare costs and outcomes in the United States to Scandinavian countries; and the final section covers recent healthcare policies of the past 50 years up to and including the Affordable Care Act. The book from cover to cover describes that the American health care system has evolved from a series of disjointed policies that were created out of necessity rather than planning. This disjointed evolution, combined with the American capitalist ethos has created a healthcare system which monetizes patients and claim that it’s healthcare providers are profit centers. Meanwhile, this counteracts the attempt of government programs and insurers to limit gross healthcare spending.
The content within the book is very strong in its persuasive nature. The authors provide clear and concise information on the overall health care system in the United States. This information is very easy to digest and is presented simply, in a way which is easy to understand and draw conclusions. In addition, the authors provide a very compelling case how the Scandinavian countries are similar in citizen mentality and structure to that of the United States. This provides a great backdrop and insight to use as a benchmark for the United States. For example, there is a table comparing infant mortality, life expectancy, low birth rate, and maternal mortality of the United States and several benchmark countries which is particularly effective in showing how Norway is far ahead of the United States in these metrics.
Where the authors fall short is in the details. Although it is very easy to digest this book, it mostly describes broad healthcare concepts, with little depth on the interactions between providers and insurers, or about the nuances of policy. In addition, only the Scandinavian countries are used as benchmarks, while there are several other countries that are more efficient in healthcare than the United States. For example, India is very good at controlling healthcare costs and maximizing value from their assets, which the United States could learn from. Lastly, specific healthcare programs and methods are not discussed. Innovation and new medical methodologies created in the United States are barely mentioned, which I think is an important component of US healthcare expenditure.

Overall this is a great book for an introduction to healthcare in the United States.

[Juan Morales Perez · Rating 4 out of 5]

This book is the book for anyone interested in how health and health behaviors do not occur in a vacuum. The book discusses the historical basis of many US practices to health promotion and prevention, while contextualizing everything within existing social research. As someone who reads sociology, I appreciated the discussion of the professionalization of medicine, American individualism and exceptionalism as key way to understand social issues associated with health and health care as an institution.

On the whole I’d call this a great way to read and learn about the social issues facing the our health care system.

[Jack · Rating 4 out of 5]

Social determinants of health, it's all the rage in healthcare, but in this book, Bradley goes further than other works which simply diagnose how critical social factors are in contributing to health outcomes, she paints a more complete picture of how America's paradoxically poor health outcomes despite extremely high spending on healthcare is in large part due to our under-investment in social services.

The seminal chart presented in this book is a figure that shows the aggregate of what countries spend on both health services and social services as a % of GDP, and with social services included, the US looks to be middle of the pack compared to OECD developed countries at just over 25%, but it was anomalous in spending the majority of this amount on healthcare. While we spend <$0.60 on social services for every dollar we spend on healthcare, OECD on average spends TWO dollars on social services for every dollar on healthcare (the ratio has converged towards normal since then, but is still an outlier amongst developed nations).

The structure of the book follows a straightforward syllogism by chapters, 1 - introduction and setting the scene, 2 - historical roots of how and why America bifurcated the health and social sectors, 3 - case studies of stories from the front lines of health and social services to illuminate acute challenges faced by patients and providers, 4 - Scandinavia as a case study in contrast of how a society might integrate health and social services, 5 - case studies of new emerging models of health and social services integration in the US, 6 - how past national efforts to integrate social and health services have failed, and 7 - summary and conclusion.

I especially liked
2 - history and cultural context, always helpful, most of this retreads on what Elisabeth Rosenthal's masterful "An American Sickness" (what is it with Elizabeth's and healthcare books...), but nonetheless a good recap. Bradley dives deeper though on the cultural historical context, describing cultural roots of our aversion to the welfare state (due to a lack of feudalism in our history no less...) and expectation that social services can be purveyed by religious charities. The emergence of this working cultural theory has been fed by natural American rugged individualism, and poses a huge barrier to addressing the issue at hand.
3 - case studies of what the "medicalization" of wellness actually means for patients and providers, how this translates to a frustrated doctor who can see the social issues but does not have the tools to address it in their patients, and both patients and doctors who are trapped in a system that incentivizes everyone to see even social problems as medical ones (when all you have is a hammer...).
4 - Scandinavia, especially the takeaway of the importance of LOCALIZING decision-making around structuring these models of integrated services, so the answer for the US is probably NOT a monolithic Federal policy, but rather a policy of enpowering and enabling local government to coordinate servicing these needs.
6 - fascinating history of past good-faith national efforts of addressing this problem, including LBJ's great society (I was fascinated to learn that FQHC's emerged from LBJ's great society legislation, and started out as "neighborhood centers" which was run through the now defunct Office of Economic Opportunity) to Nixon's HMO act and the subsequent HMO boom. I've always wanted to read up on the context behind the 90s HMO bust, but found it weirdly ignored (at least the whole arc in its entirety) in most healthcare histories, but finally it gets a satisfying treatment here. Also embedded here is a history of how the powerful physician and hospital entrenched interests have often prevented a shift in thinking towards new models of care integration.

After finishing this book, I can't help but on a basic level change the way I think about the way forward in healthcare. Maybe the new care model shouldn’t be centered around principles of evidence based medicine, or pop health analytics, or home based care, or care management and the like, rather these should all be secondary tactical tools, but the primary theme should perhaps be RESTORE/BUILD/STRENGTHEN THE DOCTOR PATIENT RELATIONSHIP. Of course we must also make sure that doctors, once they have that relationship of trust again, does practice in a responsible and data informed way, but if this becomes the rallying cry, we can reverse the modern tide of medicine reducing what used to be a relationship-based vocation into a transactional trade. If we can restore the relationships, and give providers the right tools, then providers should naturally identify and want to address not just purely medical needs but help to address social needs that affect health.

A second thought that arose was maybe there is the need for a parallel but separate social work structure with healthcare organizations, a shadow structure to the clinical structure, which will define standard and best practices and measure performance on the social services front to match the clinical leadership structure. Perhaps it's incomplete to think of social workers as a contributing member of the care team which still revolves around the MD, perhaps we should think of the Social Worker as just as central and important as the PCP in their responsibility and authority to direct care and treatment. Should healthcare orgs have chief social officers? Social patient panels? It's always a good sign when a book sparks new ideas in your head.

[Case Chun · Rating 4 out of 5]

A lot of statistics and comparisons to other healthcare systems that brings up a lot of questions of how healthcare is managed in the States. This book relies on data from the time it was published so there are some things that have not been updated, such as the metrics of Accountable Care Organizations (ACOs). Would love to see a follow up of their case studies.

[Ariadna73 · Rating 5 out of 5]

This book says that the money keeps going to the wrong place: doctor's and insurance companies's pockets; instead of going to social programs to help people eat better, have better shelter and clothing and a generally bettef life that will keep them away from doctors and hospitals.

[Craig Becker · Rating 5 out of 5]

See this post at: https://positivehealthleadership.org/...

My reading of the fantastic work by Bradley and Taylor in “The American Health Care Paradox: Why Spending More is Getting Use Less” led me to strongly recommend you also read this book. They use powerful data to document how we are all in this together, and we do best when we help each other. With powerful clarity, they document something we all already innately know, better health cannot be achieved through medical means. They end the book with: "To that end, an ever-growing body of literature suggests that broadening Americans’ historically narrow focus on medicine in pursuit of improved national health may ultimately hold the key to unraveling the spend more, get less paradox."

They explain, although medicine is good at medical care, America does have the best emergency care, our lives and health are not linear, they have multiple causes. These multiple causes mean we need to also, if not primarily, focus on the social, behavioral and environmental non-medical determinants of health because it is more effective at improving quality of life as it also decreases the need for medical care.

They also share how through history, America has made an attempt to support and improve non-medical care with community health centers, HMOs, and now ACO’s. Unfortunately, the power of the medical lobby and their concern over losing paying patients caused these efforts to be watered down to a focus on medical care. Without question, medical care is crucial for specific illnesses. Medical care is vital for acute, short term care, I am alive because of it. However a larger content is more predictive and necessary to improve public health. Bradley and Taylor also show us many successful efforts in America that resulted in better health. These attempts also were significantly less expensive and better for all involved.

They also explain that, despite what we hear, America Actually Spends Less On Healthcare. With clarity, they demonstrate America does NOT spend the most on healthcare if you account for all the factors associated with health, not just medical care. Medical care and social services are interrelated. Nations that spend more on social services enjoy a higher quality of life and better health and spend much less on medical care – because it is not needed. America spends the most on treatment and rescue care because America’s system neglects the social, behavior and environmental determinants of health.

America’s neglect of social, behavioral and environmental determinants of health has resulted in very bad outcomes. Despite spending so much on medical treatment, America lags other peer nations in
Life expectancy, Infant mortality, Low birth weight, Injuries and homicides, Adolescent pregnancy,
Sexually transmitted diseases (STDs), HIV Aids, Drug related deaths, Obesity, diabetes, Heart Disease,
Chronic lung disease, and Disability rates.

Quite an indictment of our current system. As they explain, medical care is good at treating disease, what it is designed to do, but it is not good at creating health because it is not designed to do that. Medicine is about eliminating disease. We must remember health is the PRESENCE of physical, mental and social well-being and NOT MERELY the absence of disease and infirmity.

[Adam · Rating 4 out of 5]

This is not an all-encompassing book that covers all the reasons why the American healthcare system is broken. That's okay, because it offers a good explanation of one particularly strong element that is undermining healthcare in the United States: viewing healthcare as medicalization instead of as part of a system. American Exceptionalism and individualism has given us a system in which we view medicine as something that can fix all the problems that come with thinking we can do whatever we want to our bodies because of our liberties. Instead of doing the hard work - diet, exercise, regulate exposures to toxins, etc - we expect medicine to make up for our shortcomings. The authors argue this is the main reason why we have worse health outcomes than other wealthy countries. They're exactly right.

It's a succinct and accessible read. They start with a brief summary of how the healthcare system developed the way it did in the United States. They compare it with those in other wealthy countries, notably systems in Scandinavia. They provide examples of organizations in the U.S. that view medicine as part of the equation that is health to show the reader what type of things are possible when we think outside the box. I could have done with less interview snippets, but definitely a worthwhile read.

[Noor · Rating 4 out of 5]

Rounded down to 3.8, good analysis of the shortcomings of the US healthcare system through anecdotes + historical context + comparison to nations leading in the health and social support sectors. I enjoyed the emphasis on collectivism in achieving a functional, supportive society as seen across the Nordic countries and it made me hopeful but weary in terms of where we are in the US now. The suggestions and recommendations for the US to improve their healthcare system through a more holistic approach when managing health/patients felt well researched as well. My only issues were the last fifth of the book became a bit dull and my attention was lost, and I felt like some pieces were a bit repetitive or obvious (which may just be because I’m familiar with the topic).

Overall, well researched and a good introduction into the realities of the poor healthcare system in the US and how we got here.

[Vanessa Hague · Rating 5 out of 5]

When we talk about the health care debate, people seem to align themselves on either side of a false dichotomy: empathy vs affordability. Our options are far more complex than what most common political dialogue would suggest, and it turns out we can actually help more people, while spending less, while - in many cases - saving even more money in the long run. Elizabeth Bradley concludes with case studies showing how, in different parts of the country, that very thing is already happening.

The first part of the book is about the history of medicine, and health care, in our country. It's a tough slog but well worth it once you see how it all comes together. I wish 1) everyone would read this and 2) we would collectively decide - on either side of the aisle - to demand more innovative solutions. Because we can do so much better. We can.

[Erin · Rating 4 out of 5]

As a student of health systems, there wasn't much in here that was new to me. But for those looking for a helpful overview of so much of the research, contextualized within the realities of American culture, this is a great book. To sum up the problem: there's always so much talk about how the US spends the highest % of GDP on health care but ranks quite low on a handful of important health measurements compared to other high-income countries. But research by these authors shows that this is taking a narrow view of what spending on health looks like (i.e., only looking at *medical* care specifically). When including all health-related social services spending (such as on housing, welfare, unemployment benefits, education, etc.) by comparable nations, the US is actually spending much less of our GDP on the things we know matter to our health.

[Mad Stork · Rating 5 out of 5]

Well articulated, researched, and educational read. It helped me understand the evolution of the medical profession/healthcare and social services in the US. Furthermore, it highlighted how and why they evolved separately and what the long-term consequences of this are. It was also helpful to see this contrasted with European healthcare history (eg Bismarck systems and Norway) and how those have been shown to be more effective. It also shows examples in the US in which the intertwining of both improves patient outcomes at a cheaper price while still in the vein of “American” values - as defined by the world value survey. It talks about the possible paths forward etc. I learned a lot and am happy I read it

[Christine · Rating 2 out of 5]

Not gonna lie. Thought this was boring and I really like learning about different perspectives of healthcare. DNF’d only because I felt like I was gaining very little with the amount of time that I was reading it. I got side tracked easily which isn’t a good sign for me to continue on reading a book after already feeling like I’m persisting.

The basic premise is that the US pays so much of its GDP compared to other western countries, but our health outcomes are only worsening. Authors compare the US with Scandinavian countries and other countries who prioritize incorporating social welfare as a part of healthcare. I liked that authors included data and graphs to illustrate trends etc but overall I feel like I could learn more elsewhere. 😔

[Chelsey Carroll · Rating 5 out of 5]

Read this a while back (maybe 2017 ish) and found it to be extremely insightful and well-done. Eye-opening to what the “big picture” of it all really looks like. Also can give any healthcare professionals a little bit of a meaningless feeling of being an ant who is one cog in the wheel of a giant system that refuses to pay for any preventative, protective, earlier interventions in a holistic way that would actually lead to less healthcare visits in the future in our fractured system and a system that cuts services out too early, leading to readmissions of our cases that, if looked after properly, would not need to keep falling into the same cycles outside of their control.

[Todd Martin · Rating 3 out of 5]

The conventional wisdom is that the US spends more on healthcare than any other developed country with poorer outcomes. By way of example, US health care spending was nearly $8,000 per person (in 2009), while most other developed nations spent less than $4,000. By way of health outcomes, the US ranks 25th in maternal mortality, 26th in terms of life expectancy, and 31st in infant mortality. All of which is rather depressing (don’t let it get you down though, we lag other nations in mental health care as well).

The natural question is why? Several theories have been put forth to answer this question including:
1. People are under-insured, thus they do not receive preventative healthcare measures, only entering the system when they are severely ill.
2. There is a lack of primary care physicians (more than 85% of doctors enter specialized fields of medicine).
3. Medical malpractice and tort laws lead doctors to prescribe a barrage of unnecessary tests to avoid lawsuits, driving up costs.
4. Patients demand cutting edge (aka: more expensive) technology in their treatment. Thus the $5 stethoscope is set aside to make way for the $1,000,000 MRI scanner.

In The American Health Care Paradox: Why Spending More is Getting Us Less authors Elizabeth Bradley and Lauren Taylor argue that, while these factors may exacerbate the situation, exactly none of those rationales fit the facts. Instead, they make the case that the cost of health adds up to more than the spending that occurs at the doctor’s office or hospital. A person’s health outcome is influenced by many factors, including diet, lifestyle, education, as well as access to nutrition, exercise and social services. European countries, who have better health outcomes, spend more on social services than the US. The author’s argue that this spending pays dividends in terms of healthcare costs because these proactive measures lead to a healthier population.

The quintessential example of the gap that exists in the US healthcare system is the homeless person with a chronic illness (say, diabetes). In the absence of social services, they don’t have access to insulin or a healthy diet. As a result, their condition worsens and they eventually require hospitalization. After a barrage of costly tests and treatments the patient’s condition improves. The hospital then discharges them back onto the street where the cycle begins anew. A more cost effective approach might involve temporary housing, counseling, job training, and nursing care to both stabilize the person’s medical condition, and eventually lead to self-sufficiency. Of course, evidence of such a program’s effectiveness would have to overcome right-wing ideology for an expansive social safety net to ever to become a reality in the US.

Fortunately there are many different ways that such a system could be implemented. The authors frame improved health outcomes in terms of the availability of social services, but in reality their idea boils down to the promotion of a more integrative, holistic approach to healthcare (which is hardly a new idea). An approach such as this wouldn’t just treat the illness, but would also act to promote a healthy lifestyle and to prevent illness / injury from occurring in the first place. One such proposal involves a fee structure based on health outcomes, rather than the number and type of tests and procedures performed. The authors present several other models involving a more integrated network between healthcare providers and social workers.

Criticisms:
Although the authors present their findings as if they represented a new approach to healthcare, I found the essence of their ideas to be rather commonplace. They boil down to the fact that health involves more than just an absence of disease, it includes diet, fitness, lifestyle and an absence of stress, as well as access to fulfilling relationships and rewarding work. As the Earl of Derby said in 1873:
“Those who do not find time for exercise will have to find time for illness.”
Although medical care still has treatment as its primary focus, the US healthcare system is beginning to place more emphasis on lifestyle choices and disease prevention (through such tactics as diet and wellness programs, medical screening procedures, and discounted gym memberships among others). If insurance companies find that these approaches improve their bottom line then the programs may be expanded to include additional social services in the future. We just have to acknowledge that people have the right to make choices for themselves and resign ourselves to the fact that not everyone will eat their broccoli.

The other criticism I have of the book is that the authors mention acupuncture several times as a treatment that should be included as part of a holistic approach to health (thankfully they stopped short of powdered rhinoceros horn as a treatment for erectile dysfunction). But, effective healthcare must be based on evidence, not on superstition. Increasingly, as peer reviewed studies are performed, acupuncture appears to be completely ineffective with any benefits being a result of the placebo effect. If you want to “spend more and get less” I’d be hard pressed to come up with an approach that is more effective than the use of placebo in place of scientifically proven medicine.

[Lee Radford · Rating 5 out of 5]

Americans spend more than twice as much on health care and live four years less than people in the United Kingdom. When national health care spending is compared to clinical outcomes and lifespans, America's health care system is an outlier in how pathetically bad it is. But Bradley and Taylor argue that if national social spending and health care spending are examined as a combined total, America's system is in the middle of the pack. Improvements in social factors will likely drive improved health much more than health care spending will improve health.

[Emily · Rating 4 out of 5]

This was a great companion to Social Transformation, and had many salient points to make on its own. I especially liked the section which analyzed clear similarities and differences between Scandinavia and the US as a means of showing that healthcare reform and reframing is not completely inconceivable here. I wish the authors had extrapolated on their findings a bit more as the book felt rushed at some points.

[Andrew York · Rating 4 out of 5]

Important idea that all social services are related to health and that the US is underinvesting overall. However, the book was a little light in analyzing the problem and proposing a solution, probably because the issue is so big.

“Be more like the Nordic countries” and “look at these couple examples of projects that work” does not provide a clear path on how to fundamentally address the issue.

Good book overall that provides an important idea.

[Nathan Park · Rating 3 out of 5]

Takes the stance of how the problem lies in how our social services are underfunded. US seems to spend a crap ton on health care industry, basically medicine to solve immediate pain, but fails to solve the underlying/systemic issues. People who study public policy will probably enjoy and agree with this stance; to a point I do too. I’m sure there are books out there taking a look from an economic or medical lens that I might be more fond of.

[Petty Lisbon · Rating 4 out of 5]

Closer to a 3.5

I liked how they wrote about the history of healthcare in the US and lobbying has basically made any reform impossible in the US. I liked the (hypothetical) examples for how anyone can get screwed over by social determinants for healthcare. They did a good job of explaining the Scandinavian system and why it's still possible and not a "socialist pipe dream" and possible ways for the US to move forward.

[Jesse Richards · Rating 4 out of 5]

This book makes an excellent point and everyone should read it to understand why health care in America is so f-ed up. One star off due to writing that is a little too academic and dense; but it's not a long book. The best parts were all the quotes and case studies from health care workers and patients.

[Janaya Woehnker · Rating 3 out of 5]

It was a hard book to digest in the beginning but it was surprisingly more inquisitive than I had anticipated. Overall, an enlightening and inspiring read for anyone that is a benefactor or contributor to the American healthcare system or interested in the complexities of the US healthcare system from an international viewpoint.