Last year, while doing book research in New Haven, Connecticut, we met a social worker who told us about a twenty-eight-year-old man with diabetes. He had been living in a vacant, boarded-up house; to avoid being seen there, he entered through the marshes behind the home. His shoes were full of holes, but he couldn’t afford to replace them. He also sometimes went several days without fresh food. As a result of his bad diet, he struggled to control his diabetes; after a lifetime of poor insulin control, he was starting to lose circulation in his feet.
The man had recently got two toes removed from his right foot to save his life, an operation with a baseline cost of at least four thousand seven hundred dollars, and his feet were already badly infected. Several people at the hospital emphasized the importance of keeping his feet dry, getting proper nutrition, and regularly taking his costly insulin. He was eager to do all of this, and, indeed, he became diligent about taking his insulin. But, because of his living conditions and lack of employment, it was harder to follow the other recommendations. The social worker told us that the man would likely have to get more toes removed (at an additional cost of at least nine thousand four hundred dollars); without immediate changes, he would eventually need a below-the-knee amputation (another nine thousand four hundred dollars or more) and a wheelchair to get around (in excess of a thousand dollars, in many cases).
If all of this happened, the estimated cost of this young man’s medical expenses would top twenty-four thousand dollars, paid for by a state medical-assistance program. A decent pair of shoes costs fifty dollars or less. Wouldn’t investing in shoes have been a better start?
Two years ago, health spending in the United States accounted for nearly eighteen per cent of G.D.P., almost twice the average rate among countries that belong to the Organisation for Economic Co-operation and Development. Yet the United States also has among the highest rates of obesity, diabetes, and cancer, and a below-average life expectancy, compared with other O.E.C.D. countries. Increasingly, research has indicated that there may be a paradoxical explanation for this discrepancy: the country is investing too much in medicine and not enough in addressing the social, behavioral, and environmental factors—things like diet and housing—that help create medical problems in the first place. Only about ten per cent of early deaths are related to medical care; thirty per cent come from genetics, and about sixty per cent are the result of social, environmental, and behavioral factors, according to a report by J. Michael McGinnis, Pamela Williams-Russo, and James R. Knickman. Meanwhile, the United States spends far more on health-care services than on social services. Some call this “medicalization”—that is, the treatment of social, economic, and behavioral factors as medical problems—and it is estimated to have accounted for nearly four per cent of total domestic spending on health care in 2005.
There are several reasons why American health-care costs are so high compared to those abroad: patients are given more intense care, administrative spending is especially high, health services are more expensive, doctors have a financial incentive to suggest more treatment, and people with insurance aren’t held accountable for the high cost of their care. But what if we could reduce our reliance on medical care and direct more resources to the services that improve people’s health in the first place? Couldn’t that help lower over-all health spending while also making people healthier?
We’re not the first to suggest this. The Affordable Care Act is set up so that, over time, health-care providers could be rewarded for achieving better health outcomes for patients rather than simply for providing more health-care services. (Some argue that insuring more people through Obamacare could drive up health-care costs, because it would encourage more patients and providers to spend unnecessarily on medicalization; we believe, however, that the health-care system is already absorbing many of the costs of dealing with uninsured people’s health, and that this just makes it official.)
Still, there’s more work to be done. Rather than relying almost solely on medicine to improve health outcomes, we could look at alternative interventions: adequate housing for people who seek shelter in emergency departments, better nutrition for those suffering from diabetes, transportation services for older adults who can no longer drive to their medical appointments safely. In some cases, such interventions might help obviate the need for additional medical care entirely, while in others they might make certain treatments more successful and efficient.
Homeless people, in particular, whose high health-care costs have been well documented by Malcolm Gladwell and others, may benefit from certain interventions. (In 2006, Gladwell wrote about a homeless alcoholic man named Murray Barr, who ran up a huge medical bill because of repeated stints in the emergency room and other issues.) In researching our book, we came across a group of people in Santa Monica, California, who came up with a novel approach to addressing the costs of treating populations like these. One of them, John Maceri, the executive director of the Ocean Park Community Center, opened a special section of his shelter for a small group of especially vulnerable people who were using an extraordinary amount of health-care resources.
Maceri persuaded a hospital to help fund the facility, where an on-site nurse could care for uninsured people who had been recently discharged from treatment and had no stable home; the shelter also enrolled these people in primary-care services through a local clinic. Previously, these patients had unusually long hospital stays because they had no place to go, and after being discharged they often turned up in the emergency room again, because they hadn’t had access to follow-up care while on the streets and had developed complications. Under the partnership, these patients could be discharged for follow-up care in an appropriate environment, they were seen less frequently in the emergency room, and they could access basic health-care services through the local clinic. In February of 2011, the hospital estimated that this arrangement would eliminate approximately three hundred thousand dollars in total emergency-room and inpatient charges for ten of these patients in a year’s time.
Some may reject the idea of expanding access to social services, but this is not about spending more money. It is about spending the same money more wisely. “You just get them connected to a support system,” Maceri told us. “And if you can help to get them housing, both their physical and mental health get better. It all goes together.”
Elizabeth H. Bradley is a professor of public health and the faculty director of the Global Health Leadership Institute at Yale University. Lauren A. Taylor is a Presidential Scholar at Harvard Divinity School. They are the authors of “The American Health Care Paradox: Why Spending More Is Getting Us Less.”
Illustration by Jing Wei.
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