01/29/2014 03:09 pm ET Updated Mar 31, 2014

The American Health Care Paradox: A Book Review

The American Health Care Paradox: by Elizabeth H. Bradley and Lauren A. Taylor

How medical and social services became separate, unequal and ineffective.
A Book Review by Lloyd I. Sederer, M.D.

This past December, I covered a policy meeting in NYC on "Population Health," a breakthrough event meant to accelerate movement towards what is needed to improve health and reduce costs. The path to achieving these aims turns out not to be more conventional medical services.

That policy meeting made plain that when it comes to the determinants of our health the provision of health care doesn't account for much (only 10 percent!). This was put well by Professor Paula Lantz when she wrote that Americans are prone to "Mistaking health care for health." (1)

In fact, it is our behaviors, our habits (like excessive and poor eating, more than moderate drinking, smoking, physical inactivity, high salt and processed food intake), that drive the lion's share (40 percent!) of our ill health and early demise. A remaining 30 percent of our health appears attributable to our genes -- but we now recognize, through the science of epigenetics, that DNA is turned on or off by its exposure to our environment and what we do and don't do. In other words, if we are to be healthier and live longer as a country we better look beyond hospitals, doctors and clinics.

But there is more to it that that it turns out. What has been omitted is so well expressed in Elizabeth H. Bradley and Lauren A. Taylor's book, The American Health Care Paradox: Why Spending More is Getting Us Less (Public Affairs Press, 2013). This crisp, clear and easily digestible book (which is notable since this can be a dense and soporific subject) begins by first showing how the USA is at the top of 32 developed nations in its health care spending as a percent of GDP (50 percent more or greater) yet largely sits in the cellar when it comes to life expectancy, maternal mortality, low birth weight and infant mortality.

But then the authors show how GDP analyses, heretofore, have not included spending on social welfare costs such as housing, job training and creation, unemployment insurance, family allowances, our physical environment and services that help knit a community of people together. This book traces the divergence of health care and social welfare in the USA from the mid-1850s until the present.

With this history established, the authors then redo the math: when social welfare costs are included in GDP, as they are abroad, the USA catapults up to the middle of the pack! We are modest spenders, not total spendthrifts getting such a meager return on our money.

But, needless to say, being in the middle is hardly American, nor aspirational. And it is not affordable, to boot. Imagine, as well, if we were getting our money's worth for what we are spending: we could either be a far healthier nation, have lower medical costs, or both. In other words, we are not off the hook after the calculations are redone. We have work to do, a lot indeed.

Yet the authors are sanguine about the future of health, and even our country. They say, don't despair since there reason for hope, maybe we can learn from abroad. Especially Sweden, Norway and Denmark. But even though the authors argue that we share common values with the Scandinavians (like personal freedom, the utility of competition, and how science and technology can serve us) they do appreciate that Americans have not proven themselves good students of international lessons. If we cannot rely on simply importing solutions, we will have to construct a way out that is more culture bound to U.S. notions of trust in others, accountability, the role of government and health itself -- and of course, bridge the historical and operational separation of health and social welfare systems they so ably illustrate.

The book has ample individual patient examples of our failures as well as organizational examples of American innovation and promise. There is a way out of the paradox of paying too much for too little, they assert. There are ways to spend money more wisely. I think so, too -- and I suppose I am not alone in concluding it will be hard, messy and may take more time than we have.

For those that may contest their findings as the product of more bleeding heart liberalism, the authors state "Don't misconstrue our analysis as little more than a call for more robust safety net services." (p. 191) Instead, their message is that health eludes all socioeconomic sectors (rich and poor) who are not living in safe, secure homes with environments that offer opportunities for education and work as well as protections against life's misfortunes (like unemployment insurance and family benefits). Of course, the poor and minorities are disproportionately impacted since the social dimensions of their lives are far more deprived than those of the "one percent."

The authors of "The American Health Care Paradox" entreat Americans to use "...evidence rather than ideology." (p. 197) While I suspect unintended, this message seems to resonate with so much else that that has become stuck in this country today.

So, who is responsible for our health? The answer seems to be everyone! Accountability lies with each person, community, doctor, the medical care and social welfare systems, insurance companies, government (surely there is something between the "nanny state" and "live free or die"?), media and culture. The problems we face in health care and social welfare are so vast that their solutions must embrace about everything known and in all sectors -- and then all the remedies identified have to be thrown against the wall of ill health in order for a good bit to stick.

"Life is short, art long, opportunity fleeting, experience deceptive, judgment difficult," cautioned the great Greek physician, Hippocrates. We better start throwing since time isn't on our side.

1. Lantz, P, et al: Health Policy Approaches to Population Health, Health Affairs, Vol. 26, No. 5, 2007, pp 1253-57.


Dr. Sederer's new book for families who have a member with a mental illness is The Family Guide to Mental Health Care (Foreword by Glenn Close).

The opinions expressed here are solely mine as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.

Copyright Dr. Lloyd Sederer