Photography from ‘The American Healthcare Paradox.’


Austin Jaspers: How did your collaboration on The American Health Care Paradox begin?

Lauren Taylor: The book really started with a peer review article back in 2010 that examined health and social service expenditures in 34 OECD countries.  It reframed the conversation around health care investment in the United States.  It found that social service investments were critical and showed that the ratio of health to social service spending was very predictive of some key health outcomes like life expectancy, infant mortality, and maternal mortality.  Following the publication of that paper, Betsy and I wrote a New York Times op-ed that was very well received.  We were deluged with emails and among them was an offer to do this book – an opportunity to expand upon a central thesis and dive deeper into circumstances surrounding the U.S.’s allocation of resources in the health and social service sector.

AJ: What is the “paradox?”

Elizabeth Bradley: The paradox is that U.S. spends double what the average OECD country spends per capita on health care, but our health outcomes are among the very worst in the OECD.  Most people would think that if you are spending more on medical care, you would get more for it.

AJ: Your research and writing takes a global perspective to understand the paradox of American health care.  What countries or settings offered useful parallels? What were the limits of those comparisons?

LT: When we were looking to make international comparisons, we made some careful decisions: We had experience working with the National Health Service in the U.K. and we thought about going to Canada. But we decided not to go that direction because we felt that those comparisons were somewhat tired.  When we looked at the statistics to see who was outperforming the rest of the globe, it was not England or Canada, but some of the Scandinavian countries.  These were countries that were getting attention for well-planned and coordinated health and social service systems. The way that we have written about them, they are not to be taken as models for what the U.S. should do.  Rather, they are appropriate comparisons because they are very different from the U.S. model.   The hope is that we can learn from them, but take lessons and adapt them in a uniquely American way.

AJ: What changes are feasible in America’s existing economic and political structure? What is the first step and who should drive these changes?

EB: The book is not about making policy recommendations, instead it illuminates this paradox.  We look at evidence to try to understand it better.  Hopefully, it will provoke a new discourse about health in the U.S.  It would be premature to make policy from this, though we have thought about practical implications.  What do you do first? Start to talk about health differently.  There is a lot more that determines the health of our population than our medical care system.  Getting that message across is important to all sectors.  The book gives the implication that incentives must be aligned: our health care system must address the social determinants of health and our social services coordinate with health services.  Over the long term, we would hope to see infrastructures emerge with new models for caring for people that consider the whole person and the myriad of tools you can use to bring about health – not just medical care

AJ: How do social services impact population health?

LT: There’s a strong literature suggesting both the impact of social determinants of health.  Sixty percent of premature deaths can be attributed to social, behavioral and environmental factors.  We drill down into the literature about specific social determinants of health – like education or employment – and their power to confer important benefits to health over the long term, and reduce health care spending.

EB: In the book, we highlight several cases of individuals that bring to life how a lapse in a social service creates health problems.  You take Barry, for example, who is a well-educated, business executive.  He falls on bad luck, gets laid off in 2008, and then tries to start other businesses that go bad.  Over time, he becomes tremendously depressed over this and picks up poor eating habits.  He was always heavy, but becomes substantially obese.  He loses his house and doesn’t have insurance.  This person is looking at a lifetime of tremendous chronic illness, which began from problems with employment.  In another example, Martha is a person who called an ambulance every other week because she was lonely.  She got transported to the hospital along with a full medical work-up – every other week.  If she had had someone she could have talked with or an adult day care center, such services might have reduced her reliance on medical services and reduce the expenses substantially.

book cover

Cover of ‘The American Healthcare Paradox’

AJ: How can existing health care organizations integrate social care with health care?

EB: Physicians know that this is a huge problem.  They wish they could work with a social worker, to prescribe housing or employment beyond medical care.  The question is: how do we create communication between physicians and people working in social services?  We highlighted several organizations that went out to integrate physicians with community centers.  It can be done; now we need to know how it can be scaled.

AJ: What about U.S. health care discourse makes you optimistic?

LT: I’m optimistic that everyone is focused on health right now – we really have the attention of the nation.  The President has placed a spotlight on health in the national agenda.  The conversation as it currently stands could be broadened.  One of the key messages of the book is that the problem with health care in the U.S. is not with the health care industry itself, but lies instead with the social service sector or in our understanding of the social determinants of health.  I’m optimistic that we’re focused on this, but I hope we can broaden our horizons about what the root of the problem really is.

EB: I would add another note of optimism.  The ACA achieves the goal of insuring everyone and this forces the American public to think about how they’re using these dollars.  By virtue of the fact that we will be sharing one big pool of spending, it will be in all of our best interests to ask if we are doing this as efficiently as we can.

LT: The research on this book left us optimistic.  There are grassroots innovators here in the U.S. who are working to address health and social services in a coordinated, holistic way.  Though sometimes I am discouraged by the narrow reform conversations, the past two years of interviewing and interacting with these frontline entrepreneurs has left me optimistic.