A Challenge to American Doctors

The US spends much more per person on medical care than any other country. And yet, by commonly accepted measures of the quality of its national health system, it ranks only in the middle of the other advanced countries belonging to the Organization for Economic Cooperation and Development (OECD).

Elizabeth Bradley and Lauren Taylor argue that this “American health care paradox” is resolved when expenditures on other social services that undoubtedly contribute to improved national and personal health are taken into account. These expenditures include support for such services as housing, education, maternal and child care, disease prevention, nutrition, environmental safety, and unemployment benefits. They also involve subsidies for the very poor, the disabled, and the elderly.

The US spends a much smaller percentage of its GDP on these programs than other OECD countries. Thus, when these expenditures are added to what is spent for medical care, the total, expressed as a percentage of GDP, places our country in the middle of the other OECD countries. That is consistent with the ranking of our health care system, and so the authors claim the “paradox” is resolved.

To increase the quality of our health care system to the level now achieved by France, Germany, Switzerland, and Sweden, we would need not only to expand our investment in other social services, but also to practice what Bradley and Taylor call “a more holistic approach” to the medical care of each patient. That means more attention to preventing illness and to modifying patients’ behavior in ways that promote health.

Their argument has intuitive appeal, made even stronger by the warm endorsement given by Dr. Harvey Fineberg, outgoing president of the Institute of Medicine (IOM) of the National Academy of Sciences, in the foreword he has written for the book, and by recent reports from committees of the IOM. It is generally agreed that poor and disadvantaged populations, such as teenaged single mothers and their children, or unemployed, uneducated, and ill-housed minorities, suffer relatively poor health. So it might seem entirely reasonable to conclude with the authors that the answer to what ails our national health system lies in paying more attention to social welfare programs, preventive measures, and education. Their argument is made more attractive by their clear prose and by their many helpful descriptions and historical explanations of US health care policy. Nevertheless, it does not persuade me, and I don’t believe it will satisfy many critics who look closely at the issues.

In the first place, Bradley and Taylor pay insufficient attention to the great value Americans place on the immediate diagnosis and treatment of personal illnesses and injuries, as compared with public measures to enhance national health such as disease prevention and nutrition. In the US, prompt medical care is given far greater priority than improved public health, and it commands much greater resources. Research on personal medical care is also given a high priority, but new large investments in social welfare programs are not a legislative or political…


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