The American Health Care Paradox: Spending More and Getting Less

November 2015

1

Elizabeth Bradley, PhDProfessor of Public Health

Elizabeth.Bradley@yale.eduFollow @EHBYale

Acknowledgements

Additional Collaborators: Erika Rogan, Maureen

Canavan, Kristina Talbert-Slagle, Chima Ndumele, Leslie

Curry

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Co-author Lauren TaylorFunders

Robert Wood Johnson Foundation

Blue Cross Blue

Shield of Massachusetts

Foundation

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0

2

4

6

8

10

12

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18

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Health Expenditures as a % of GDP, 2009

*Turkey is missing health expenditures data for 2009

Knee Replacements

Kidney Transplants

MRIs

Some Very Real Benefits

4

Enduring Challenges

Out of 34 OECD Countries

25th in maternal mortality26th in life expectancy

28th in low birth weight

What determines health? SOCIAL, ENVIRONMENTAL, and BEHAVIORAL

FACTORS(60%)

GENETICS(20%)

HEALTH CARE (20%)

job training and employment

programs

supportive housing& rent

subsidies

nutritional support &

family assistance

other social services that

exclude health benefits

Social Services

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France

Swed

en

Denmark

Austria

Finlan

d

German

y

Belgium

Italy

Portuga

l

Netherl

ands

United St

ates

Spain

Norway

Greece

Hungary

United Kingd

omIre

land

OECD

Luxe

mbourg

Slove

niaJap

an

Poland

New Ze

aland

Icelan

d

Canad

a

Czech Rep

ublic

Estonia

Slova

k Rep

ublic

Australi

aIsr

ael

ChileKorea

Mexico

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

40.00

Total Investment in Health as a % GDPSocial Service Spending, %GDP

Health Care Spending, %GDP

Italy

Hungary

Luxe

mbourg

Poland

Finlan

d

Estonia

Belgium

Austria

Denmark

Spain

Norway

France

Czech Rep

ublic

Swed

en

United Kingd

om

German

y

Greece

Portuga

lJap

an

Irelan

d

Slove

niaOEC

DIsr

ael

Icelan

d

Slova

k Rep

ublic

Australi

a

New Ze

aland

Netherl

ands

Chile

Canad

aKorea

Mexico

United St

ates

0.00

0.50

1.00

1.50

2.00

2.50Ratio of Social-to-Health Spending, 2009

*Switzerland and Turkey are missing data for 2009

In OECD, for $1 spent on health care, about $2 is spent on social services.

In the US, for $1 spent on health care, about $0.90 is spent on social services.

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Does it matter?

Globally, it seems to matter

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0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2 2.20

10

20

30

40

50

60

Mat

erna

l Mor

talit

y Ra

tio p

er 1

00K

Ratio Social-to-Health Care Spending

U.S.

Countries with higher ratios of social-to-health spending have statistically better health outcomes.

Lower infant mortality Fewer low birth weight babies

Less premature deathLonger life expectancy

Bradley , Elkins, Herrin, Elbel et al., BMJ Open, 2011

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Is the same pattern found inside the U.S. across the states?

All Social _x000d_Services

Education Income _x000d_Support

Transportation Public Safety Environment Housing0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

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Social Services Spending by Type of Service (as % of GDP, 2009)

Health ca

re

Opportunity Costs

1 emergency department visit = 1 month’s rent

2 hospitalizations = 1 year of child care

20 MRIs = 1 social worker for a year

60 echocardiograms = 1 public school teacher for a year

SGIM Presidential Speech, Dr. Moran, 201516

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Ratio of social-to-health care spending*

*Medicare and Medicaid spending

LOWEST QUINTILE

MEDIAN QUINTILE

HIGHEST QUINTILE

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Ratio social-to-health spending

Percent of population that is obese

LOWEST QUINTILE

MEDIAN QUINTILE

HIGHEST QUINTILE

HIGHEST QUINTILE

MEDIAN QUINTILE

LOWEST QUINTILE

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Post neonatal mortality rate per 100,000 live births

Red: highest mortality 5th Yellow: median mortality 5th Green: lowest 5th

Ratio social-to-health spending

Red: lowest 5th Yellow: median 5th Green: highest 5th

States with higher ratios of social-to-health spending have statistically better health outcomes.

Less adult obesity, less adult asthmaFewer adults reporting 14+ mental unhealthy days

Fewer adults reporting 14+ days of activity limitations in last 30Lower lung cancer and type II diabetes mortality rates

Lower post-neonatal mortality ratesGreater physical activity and consumption of fruits and vegetables

Less smoking tobacco Bradley et al., Health Affairs, under review

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Medicalization

Two PerspectivesGive a small boy a hammer and he will find that

everything he encounters needs pounding. - Abraham Kaplan

Experience in Other High-income Countries

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Values(Scandinavia versus U.S.)

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Differences (P<0.05)

Scope of social contract

Views of income, equality and social mobility

Degrees of trust in “the other”

Similarities (P>0.05)

Personal freedom

Views about competition

Technology as source of progress

What to do?

Spend more! 28% GDP 35% GDP?

Transfer $$ from health care to social services

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Taxes? NON-STARTER

Unlikely

Incentivize collaboration on health

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What does the evidence tell us about which types of social services produce the

best health-related outcomes?

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Literature review

Total Number of Papers n=74

Positive Findingsn=60

Health Improvementn=22

Bothn=10

Null Findings n=14

Health Care Cost Savingsn=38

CONCLUSION: The literature is mixed.

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Supportive housing, andIntegrated health care and housing

Bud Clark Commons

Minnesota Supportive Housing

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Nutritional assistance for high-risk women, infants, and children as well as older adults with disabilities

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Case management and community outreach

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DOES IT MATTER?The Work Ahead

Changing Our Mental Models: Health and social services are distinct levers to achieve common goals.

Changing Financial Incentives: To promote collaboration between health care and social services.

Exposing Latent Networks: Connections already exist between health care and social services but are not always leveraged.

Health = Health Care

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Thank you

@EHBYale