BOOK REVIEW: ‘The American Health Care Paradox’: American Exceptionalism May Be Reason Why We’re Not Having Better Health Outcomes Than Other Industrialized Countries

  • Reviewed by David M. Kinchen 
BOOK REVIEW: 'The American Health Care Paradox': American Exceptionalism May Be Reason Why We're Not Having Better Health Outcomes Than Other Industrialized Countries

 The U.S. spends substantially more than other industrialized countries for health care, but we have poorer outcomes. This is the “paradox” that Elizabeth H. Bradley and Lauren A. Taylor explore in “The American Health Care Paradox: Why Spending More is Getting Us Less” (PublicAffairs, 272 pages, $26.99).

The book is an expansion of an opinion piece the authors wrote and which appeared in December 2011 in the New York Times.

 In the article — and in the present book — Bradley and Taylor reach the conclusion that previous books that cited our expenditures on health care left out the critical element: The expenditures other countries — especially the Scandinavian countries of Denmark, Norway and Sweden — make in social services.

The use of the Scandinavian experience might scare some Americans who will immediately think “Socialized Medicine, BAD, BAD!” but Bradley and Taylor reveal how the higher taxes Scandinavians pay result in superior outcomes, including lower infant mortality rates and longer lives. They admit (Pages 113-114) that Scandinavians have to wait longer for certain operations — but not for emergencies — and of course pay taxes that are at least twice as high as U.S. residents pay.

Beginning on Page 40, the authors discuss why political scientists consider why “America is generally viewed as a laggard country when it comes to its social welfare policies.” In addition to being to being unwilling to provide federally funded health insurance [with the exception of Medicare and Medicaid] “the U.S. government has been slower to fund social welfare programs, such as unemployment insurance, family allowances, and health benefits, than have most governments in Western Europe and Canada.”

Surprisingly, the authors continue, the missing link in the U.S. is feudalism! Under feudalism, the argument goes, that by the Eleventh Century, “feudalism had created a system of government in which those who possessed land sought to safeguard their serfs, who were constrained in individual freedom but protected by their lords or masters against such hazards as sickness, unemployment, and old age.”

Feudalism led to the social contract that much of Europe observes, the authors add.

I think the authors have made excellent points and they back up their conclusions with comments from experts. Now, if only we can get rid of our “not invented here” (NIH) attitude, and spend more money on social services that would reduce the need for traditional medicine….That’s a big if!

Bradley and Taylor explain — in a manner the general reader can understand —  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 and cost.

They 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 Obamacare won’t solve, this book also points a new way forward.

Here’s an excerpt from the book that presents a vital element of their argument:

 Americans do not like being mediocre in national health outcomes but like even less facing the complex web of social conditions that produce and reinforce those uninspiring health outcomes. 

In short, Americans pay top dollar for hospitals, physicians, medications, and diagnostic testing but skimp in broad areas that are central to health such as housing, clean water, safe food, education, and other social services.

 It may even be that Americans spend large sums in health care to compensate for what they do not fund in social care—and the tradeoff is not good for the country’s health….

Physicians, many of whom see almost 30 patients per day, are increasingly aware that unmet social needs are essential contributors to worse health for Americans, and that they generate substantial costs within the medical system.

 In a recent national survey of 1,000 primary care physicians by the Robert Wood Johnson Foundation, eighty-five percent agreed that patients’ unmet social needs lead directly to worse health and that those needs are as important to address as patients’ medical conditions.

Physicians further reported that if they had the power to write prescriptions to address social needs, these prescriptions would represent one of every seven they write. Top social needs were noted as fitness (by 75% of respondents), nutritious food (by 64% of respondents), employment assistance (52% of respondents), education (49% of respondents), and housing (43% of respondents).

Among physicians we interviewed, many expressed frustration that medical tools do not address the most important drivers of poor health. One chief of emergency medicine summarized his work: “We bandage them and send them out, but what they do out there is a black box. Who knows what happens then?”

About the Authors

Dr. Elizabeth Bradley is professor of public health at Yale, faculty director of its Global Health Leadership Institute, and master at Branford College. She was previously director of the health management program and co-director of the Robert Wood Johnson Clinical Scholars Program at Yale and served as hospital administrator at Massachusetts General Hospital. She lives in New Haven, Connecticut. Lauren Taylorstudies public health and medical ethics at Harvard Divinity School, where she is a Presidential Scholar. She was formerly a program manager at the Yale Global Health Leadership Institute. She now lives in Boston.

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