Is expensive health care a social determinant of health?

Health and social services expenditures: associations with health outcomes

By Elizabeth H Bradley, Benjamin R Elkins, Jeph Herrin, Brian Elbel
BMJ Quality & Safety, March 29, 2011


To examine variations in health service expenditures and social services expenditures across Organisation for Economic Co-operation and Development (OECD) countries and assess their association with five population-level health outcomes.

A pooled, cross-sectional analysis using data from the 2009 release of the OECD Health Data 2009 Statistics and Indicators and OECD Social Expenditure Database.

OECD countries (n=30) from 1995 to 2005.

Main outcomes
Life expectancy at birth, infant mortality, low birth weight, maternal mortality and potential years of life lost.

Health services expenditures adjusted for gross domestic product (GDP) per capita were significantly associated with better health outcomes in only two of five health indicators; social services expenditures adjusted for GDP were significantly associated with better health outcomes in three of five indicators. The ratio of social expenditures to health expenditures was significantly associated with better outcomes in infant mortality, life expectancy and increased potential life years lost, after adjusting for the level of health expenditures and GDP.

Attention to broader domains of social policy may be helpful in accomplishing improvements in health envisioned by advocates of healthcare reform.


To Fix Health, Help the Poor

By Elizabeth H. Bradley and Lauren Taylor
The New York Times, December 8, 2011

IT’S common knowledge that the United States spends more than any other country on health care but still ranks in the bottom half of industrialized countries in outcomes like life expectancy and infant mortality. Why are these other countries beating us if we spend so much more? The truth is that we may not be spending more - it all depends on what you count.

In our comparative study of 30 industrialized countries, published earlier this year in the journal BMJ Quality and Safety, we broadened the scope of traditional health care industry analyses to include spending on social services, like rent subsidies, employment-training programs, unemployment benefits, old-age pensions, family support and other services that can extend and improve life.

We studied 10 years’ worth of data and found that if you counted the combined investment in health care and social services, the United States no longer spent the most money - far from it. In 2005, for example, the United States devoted only 29 percent of gross domestic product to health and social services combined, while countries like Sweden, France, the Netherlands, Belgium and Denmark dedicated 33 percent to 38 percent of their G.D.P. to the combination. We came in 10th.

What’s more, America is one of only three industrialized countries to spend the majority of its health and social services budget on health care itself. For every dollar we spend on health care, we spend an additional 90 cents on social services. In our peer countries, for every dollar spent on health care, an additional $2 is spent on social services. So not only are we spending less, we’re allocating our resources disproportionately on health care.

Unfortunately, instead of learning from countries like Sweden and France, we prefer the frantic scramble to recover money from one part of the health care system only to reallocate it toward retreads of previously failed reforms. We pretend that the fresh schemes are innovative, but they are usually long on promises, short on details and often marked with an annoying acronym: H.M.O., F.S.A., A.C.O. and so forth.

It’s time to think more broadly about where to find leverage for achieving a healthier society. One way would be to invest more heavily in social services. This may be difficult for many Americans to swallow as it suggests a potentially expanded role for government.

(Elizabeth H. Bradley is professor of public health at Yale and faculty director of its Global Health Leadership Institute, where Lauren Taylor is a program manager.)


Letters, The New York Times, December 18, 2011

To the Editor:

Re "To Fix Health, Help the Poor" (Op-Ed, Dec. 9):

Although Elizabeth H. Bradley and Lauren Taylor never use the words "social determinants of health," they are illustrating the profound truth that it is the circumstances in which people live and work that determine the health status of any population, in any nation.

Along with that come some counterintuitive truths. First, that health care, while crucial to individual survival, makes at best a modest contribution to population health.

Second, that most social and economic policies are in effect health policies because of their impact on those social determinants. Even a perfect American health care system (let alone what we have now) cannot by itself fix our abysmal maldistribution of health.

When my colleagues and I worked at the nation's first community health center in the Mississippi Delta in the 1960s, our doctors saved many lives and eased much suffering.

We repaired collapsing plantation shacks. We built sanitary privies. In the face of devastating poverty, unemployment and malnutrition, we organized a cooperative farm where residents grew tons of vegetables, and we found pathways to jobs and education.

Those interventions did far more to save lives, ease suffering and improve our target population’s health than our medical care did.

Brooklyn, Dec. 9, 2011

(The writer is professor emeritus of community medicine at the City University of New York Medical School.)


By Don McCanne, MD

Opponents of health care reform frequently object to the use of statistics such as our lower life expectancy and greater infant mortality, arguing that these represent socioeconomic factors and therefore are not due to deficiencies in our health care system.

There are two problems with their position. One is that this allows them to gloss over the severe deficiencies in our overly expensive but inadequate health care system. The other is that they offer no remedies that might improve the social determinants of health, implying that misery and poverty are a simply matter of personal choice.

As this report shows, "The ratio of social expenditures to health expenditures was significantly associated with better outcomes in infant mortality, life expectancy and increased potential life years lost, after adjusting for the level of health expenditures and GDP."

The United States has distorted this ratio by spending so much on health care (much misdirected) while spending so little on social services.

We need to spend more money, but not on health care. We are already paying the health care delivery system enough, but we need to have a far more efficient financing system that improves the allocation of those payments.

Where we need to spend more money is on public social services, in the broadest sense of the term. The comment by Jack Geiger shows that it is not so much a matter of money as it is a matter of personal and societal dedication, supported by strong public policy.

We can make America a far better place for the least of us and for the rest of us as well. To accomplish that, we're going to have to do better in promulgating the virtues of egalitarianism. We certainly could use more help from the One Percenters.