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


Why, when the U.S. spends more money on medical care for its citizens than any other country, are Americans getting sicker and dying younger? The director and program manager of the Global Health Leadership Institute at the Yale School of Public Health provide provocative answers for the post-Obamacare era.

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

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Why, when the U.S. spends more money on medical care for its citizens than any other country, are Americans getting sicker and dying younger? The director and program manager of the Global Health Leadership Institute at the Yale School of Public Health provide provocative answers for the post-Obamacare era.

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Editorial Reviews

Publishers Weekly
Bradley, faculty director of Yale University’s Global Health Leadership Institute, and Taylor, the institute’s former program manager, contrast American healthcare models with the much more successful models in Denmark, Norway, and Sweden. The Scandinavian model, a dramatically more holistic approach envisioning citizen health as inextricably linked to national welfare, views greater spending on housing, education, employment, and nutrition as necessary components of healthcare outcomes, resulting in less overall spending with far greater results. The authors assemble an expansive study of representatives from the health-care and social sectors, including hospital administrators, social workers, physicians, police, emergency service personnel, nurses, educators, and pharmacists to demonstrate the need for integration between medicine and social welfare in the U.S. The disconnect between social services and health care, and the deeper historical schism between public and private interests, emerges as the reason why the U.S., which ranks first in healthcare spending, is mired in disappointing health outcomes. Admirably presented as an apolitical examination of an urgent situation, Bradley and Taylor’s carefully researched and lucidly reported findings, including innovative approaches in Connecticut, Oregon, and California, offer what appears to be an easily rendered fix, but their equally striking depiction of uniquely American hostility to government involvement in private matters, exposes a daunting uphill battle. (Nov.)
From the Publisher

The American Health Care Paradox” has enough intellectual heft to bring an opera house to its feet. Drawing on data from dozens of international and domestic site visits, wide-ranging scholarly studies and in-depth interviews with patients, practitioners, health care administrators and social service staff from all over the world, the authors tackle the unenviable task of explaining why we think of health care the way we do—to the near total exclusion of social services. And they manage to do it with astonishing clarity, conciseness and narrative ease.”—Pauline Chen, the New York Times

“An important attempt to shift the discussion on health in the United States”—Kirkus

“Their argument has intuitive appeal…[and] is made more attractive by their clear prose and by their many helpful descriptions and historical explanations of US health care policy.”—Arnold Relman, New York Review of Books

“Admirably presented as an apolitical examination of an urgent situation, Bradley and Taylor's carefully researched and lucidly reported findings…offer what appears to be an easily rendered fix, but their equally striking depiction of uniquely American hostility to government involvement in private matters, exposes a daunting uphill battle.” —Publishers Weekly

"If we’re so rich, why aren’t we healthier? I’d wondered about that for years, always assuming it was a medical question with a medical answer. I now know the answer lies not in what happens in our hospitals but what happens (or fails to happen) in our social services. This compelling, groundbreaking, and utterly persuasive book has opened my eyes." —Anne Fadiman, author of The Spirit Catches You And You Fall Down

"This book provides new insight on why it is the United States' is spending so much on medicine without seeing commensurate health outcomes. Bradley and Taylor provide a clear account of life in the chasm between health and social services, where so much of our health care investment is lost, and put forth concrete ideas on how we can do better."
Dr. Paul Farmer, MD, PhD, Harvard Medical School, Brigham and Women’s Hospital, Partners In Health, and author of To Repair the World and Haiti After the Earthquake

"Bradley and Taylor have identified social services as the unnamed culprit behind high health care costs and poor outcomes. Highlighting the non-medical determinants of patients’ health may not only make physicians’ jobs easier but also prove to be a prudent strategy for payers. This book offers an important reality check about what actually creates health in the United States."
William Gillespie, MD, Chief Medical Officer of Emblem Health, and president of AdvantageCare Physicians

"It seems like there are daily stories of skyrocketing medical costs here in the US coupled with our bad health outcomes compared with other developed countries. This book argues compellingly that we may have been looking for solutions in the wrong places. We won’t find the answers by changing medical payments or improving quality of care as important, as those are. But rather that health begins, is nurtured, protected and preserved in our families and neighborhoods—where people live, learn, work and play. The authors find that supporting families and children in ways that make their houses, neighborhoods and schools secure and enjoyable pays off in health in concrete and measurable ways. It is time we started to get serious about building a culture of health and making it easier for people to live that kind of life than merely paying the costs to repair the damages from injury and disease." —James S. Marks, MD, MPH, president and director of Health Group at the Robert Wood Johnson Foundation

"The challenge of addressing social as well as health needs is daunting. One could become “paralyzed by the complexity inherent in the relationships among health, social services, and health outcomes, and…consider strategic action all but impossible.” The book provides a counterweight to such pessimism. The authors examine four case studies of successful “home grown innovations” that provide evidence that it is, in fact, feasible to integrate social and medical services."—Health Affairs

“These authors offer us a comprehensive view of our healthcare system. I enthusiastically recommend this book for all nurses.” —American Holistic Nurses Association

"The U.S. has worse health outcomes than other wealthy countries not only because of a deeply flawed insurance system, but also because it spends less than other countries on the fundamentals of life that affect people’s health, including education, housing, good jobs, nutrition, and environmental protection."—World Wide Work bulletin

Kirkus Reviews
Bradley (Public Health/Yale Univ.) and Harvard presidential scholar Taylor examine why Americans are less healthy than others around the world, even though the United States spends more on health. The authors show that comparisons between health expenditures and outcomes are misleading since they count different things. The U.S. for example, outspends other advanced sector countries in gross national product terms, but measures of life expectancy, infant mortality and maternal survival are worse. Deconstructing numbers and interviewing professionals has led Bradley and Taylor to conclude that social welfare expenditures ought to be included with health care numbers to bring about a more realistic ranking. The United States is currently in the middle of the pack. To emphasize their point, the authors compare the social welfare spending of the U.S. to that in Scandinavian countries. For example, they demonstrate that helping a diabetic with $50 for new shoes can help to avoid the expenditure of $30,000 for the surgery that follows a visit to the emergency room. They insist that medical costs increase due to a lack of attention to the prevention and early treatment of many easily managed conditions, and they point to the public health benefits of programs for child support, income maintenance, and housing and employment support. The authors pair their comparison with a historical review of U.S. health care policy, showing how the present hospital-dominated arrangements developed out of compromises over repeated efforts to implement health programs. They also review the opposition to public health from the American Medical Association since the New Deal. Accused of advocating for poverty programs, Bradley and Taylor insist that their objective is to improve the effectiveness of spending by broadening access. An important attempt to shift the discussion on health in the United States.
Library Journal
★ 12/01/2013
Bradley (public health, Yale Univ.) and Taylor (former program manager, Yale Global Health Leadership Inst.) take a fresh look at the reasons why Americans pay more for health care and yet are not as healthy as residents of other industrialized nations, specifically Scandinavian countries. The authors interviewed more than 80 health policy specialists and consumers to help formulate their theories. A key factor is the amount of money other countries spend on social services, treating not just a patient's physical needs but the whole person. The authors consider many factors, such as the necessity for professional collaboration, beliefs in the causes of illness, views on self-reliance, the Scandinavian emphasis on the collective—rather than the individual—good, and the role of government in a democracy. They offer encouragement to programs that have improved the health of individuals in selected American neighborhoods and suggest ways to expand these programs. The Affordable Care Act, aka Obamacare, focuses mainly on providing health care to those previously uninsured, but the authors state that it will most likely not address the root cause of the paradox. While there are many contemporary titles about health care, there is little information available in book format about this specific conundrum. Chapter notes are also included, from professional journals, books, and governmental websites. VERDICT This remarkably well-written, lucid work is highly appropriate for public and academic libraries.—Martha Stone, Treadwell Lib., Boston
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Product Details

  • ISBN-13: 9781610392099
  • Publisher: PublicAffairs
  • Publication date: 11/5/2013
  • Pages: 272
  • Product dimensions: 6.30 (w) x 9.30 (h) x 1.20 (d)

Meet the Author

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 Taylor studies 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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Read an Excerpt

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?”

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Table of Contents

A Note on Quotations vii
Foreword by Harvey V. Fineberg ix
Preface xiii


Appendix A: Interviewees 199
Appendix B: Social Values in Scandinavia and the United States: Similarities and Differences 203
Appendix C: Accountable Care Organization
(ACO) Performance Measures, 2012 209
Notes 213
Index 237

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