Book Review: The American Health Care Paradox Why spending more is getting us less. By Elizabeth Bradley and Lauren Taylor published in 2013 by Public Affairs, NY.

I read this book upon the recommendation of a friend from a healthcare quality committee that I am part of. It is common for people in the healthcare quality space to commiserate together on high costs of care and poorer (on a relative scale) quality. This book makes a solid argument that health of a population depends on much more than healthcare. Income, education, housing, nutrition, fitness, stress and social relationships have an extremely important role. Similar to genomics or proteomics, these characteristics make up each of our unique ‘personome’, much like each of our genome or microbiome.

Elizabeth Bradley and Lauren Taylor put together this very insightful book after interviewing eighty healthcare and social policy experts, researchers, administrators, and leaders around the world, and of course a lot of research on why US is getting less returns on investments in healthcare compared to peer countries. In the foreword, Harvey Fineberg, former president of the Institute of Medicine, notes that in the US, healthcare is not a right, like there is no right to education or to work. At the heart of the book is the argument that increase in social service spending is needed in order to maximize return on investment in healthcare. The book begins with the story of 28 year-old Joe, a homeless man with type I diabetes and no money for fresh food or shoes. Following a foot injury he sustains, he develops a serious infection that requires amputation of his toes that costs the local hospital $30,000 which essentially comes from the taxpayers. A decent pair of shoes to prevent the foot injury would have cost the taxpayers $50.

The 2013 Institute of Medicine report, ‘Shorter lives, Poorer health’, notes that among the 34-member OECD nations, US ranks 25th in maternal mortality, 26th in life expectancy, 28th in low birth weight, and 31st in infant mortality. Of the investments in healthcare, 31% is spent on hospital care, 20% for physician and clinic services, 10% for prescription drugs, and the remaining for everything else ranging from dental care to mental health care to home health services, etc. Healthcare spending in the US is 18% of GDP and spending on social services is less than 10% of GDP. Countries like France, Sweden, Austria, Switzerland, Denmark and Italy spend 20% of their GDP on social services. So, the combined spending on healthcare and social services in the US is modest compared to peer countries.

The book has an excellent discussion on the bifurcation of health and social care sectors in the US, and describes real life challenges because of the boundaries between the two sectors that makes a professional collaboration difficult. Moreover, US is different from Western Europe in not having a unifying code for social welfare at the federal level. There are several examples in the book to illustrate that when a person suffers extreme emotional depletion (say, loss of spouse) or temporary financial hardship, the person goes into a downward spiral and the healthcare sector bears the brunt of an inadequate social service sector. Having worked in several public safety net hospitals, I don’t even need to see data to believe these stories. Physicians like me do not have the power or ability to address social needs. A holistic approach requires professional collaboration between health and social service sectors and increasing people’s ability to take care of themselves, in order to create health for populations. An excellent example of innovation to improve quality of people’s lives is La Palestra in New York City. The organization’s president puts it very elegantly, “The pain is not the problem. The problem is the problem.” Another innovative model is the Care Transitions Innovation (C-train) at Oregon Health Sciences University where the disadvantaged patients are transitioned from the hospital back into the community through a multicomponent care program. The book also has an interesting comparison of social values in the US vs. Scandinavia. Overall, I greatly enjoyed reading this book and developed some fresh perspectives on a problem that affects my work life every day.

Suggested Additional Reading:

  1. Personomics. Roy C. Ziegelstein, MD, MACP.
  2. U.S. Health in International Perspective: Shorter Lives, Poorer Health (2013). Institute of Medicine. National Academies Press, Washington D.C.
  3. 3. La Palestra