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Life Question: Do You Want Health Care or Do You Want Health? Pick One

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Burden Lundgren
May 23, 2017

I always get annoyed when I hear about efforts to bring health care to the homeless. It’s not that anyone should be deprived of health care. But what the homeless need is health, and what they need for health are homes. Health care in the absence of the basic conditions necessary for health is a near futile endeavor.

This was brought home recently by the budgeting issues in Washington. The President’s budget proposal was released at the same time the “Repeal and Replace” debate was taking place in the House of Representatives. Although there was some outrage at the severe social services cuts in the budget, the overwhelming amount of news coverage and most of the political heat went to “Repeal and Replace”. But, if we want health, not just health care, we should have been paying more attention to the social services cuts in the budget.

It is a truism (which happens to be true) that other developed countries pay half as much for health care and have better outcomes than we do. Arguments as to why this should revolve around lower drug prices, lower physician payments, hospitals that are health care institutions rather than palaces, a reduced use of technology and even dark ideas about rationing care. But there is another place to look.

Health status does not depend primarily on health care, but rather on meeting basic economic and social needs. Poor nutrition, poor housing and, above all, poor education, lead to sicker and shorter lives no matter how much health care is available, and other developed countries pay much pillsmore attention to improving social and economic conditions for their populations than we do. Of 35 countries in the Organization for Economic Cooperation and Development (OECD), the U.S. ranks 25th in expenditures for social and health services/GDP. But OECD countries spend 6 percent of their GDP on health services. Our health services spending is nearing 20 percent. Much more of their money is going to social services. The utility of our approach is brought sharply into question by our most basic public health statistics. We rank 28th of the 35 in life expectancy and nearly dead last in infant mortality rates. To that point, a BMJ study found higher non-health social service expenditures were significantly associated with lower infant mortality and longer life expectancy. The Commonwealth Fund found also that lower social service expenditures are associated with a higher prevalence of chronic disease. During the presidential campaign, what have been called “deaths of despair” were brought into focus as the extent of the opioid epidemic was revealed. A Brookings Institution study has suggested that deteriorating social and economic conditions, especially among working class whites, has led to substantially increased deaths from drugs, alcohol and suicide.  The U.S. answer to all these problems is simply to throw more health care at them.

Why is this country so averse to investing money in health where it really counts? In their book The American Health Care Paradox: Why Spending More is Getting Us Less, Elizabeth H. Bradley and Lauren A. Taylor look at the differences in how the “social contract” is viewed here and in the Scandinavian countries. They state that Scandinavians view their government as protective, as a way to bring them all together. The basis of the American perception of government lies in the rebellion against King George, an experience which left them suspicious of government, largely believing less government equals more freedom. But a Danish health administrator quoted by Bradley and Taylor opines restrictive programs like food stamps actually limit the freedom of poor people, that they have greater personal freedom if simply provided with a minimum income. A Swedish professor states, regardless of their backgrounds, Swedes are supported from childhood through old age by their government. In America, many mock that as a “nanny state.” Others argue that people won’t work hard if we have a generous safety net. But labeling something doesn’t constitute an argument, and there is little to suggest that protection from life’s vicissitudes contributes to a lack of initiative.

Here in America, increasing income inequality is bringing economic insecurity to many more people. With a reduction in resources for social services, it looks like more poor people will be living without heat in the winter, more children will be hungry, more old people will be alone and neglected. They will get sick. Then — maybe — we’ll give them health care.


Author: Burden S. Lundgren, MPH, PhD, RN practiced as a registered nurse, specializing in acute and critical care. After leaving clinical practice, she worked as an analyst at the Centers for Medicare and Medicaid Services and later taught at Old Dominion University in Norfolk, Virginia. She has served as a consultant to a number of nonprofit groups. Presently, she divides her time between Virginia and Pennsylvania. She can be reached at [email protected]

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The American Society for Public Administration is the largest and most prominent professional association for public administration. It is dedicated to advancing the art, science, teaching and practice of public and non-profit administration.

One Response to Life Question: Do You Want Health Care or Do You Want Health? Pick One

  1. Minch Lewis Reply

    May 23, 2017 at 2:41 pm

    Excellent analysis. (I may have rated this with a 2; I meant to rate it with a 4, but didn’t hit the right key. )

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