Poverty and Health: A Connection We Can’t Ignore

May 14, 2012

In a New York Times op-ed last December, Elizabeth Bradley and Lauren Taylor wrote about the study of global health spending published they published in the journal BMJ Quality and Safety. Their analysis broadened the concept of international health care spending to include spending on social services.

Their findings were significant and ought to help us all think about health care in a different way.

When we look at health care spending in isolation, as we often do in the U.S., we conclude—completely accurately—that the U.S. spends far more per capita on health care than any other country in the world (40+ percent more than our nearest neighbors).

But Bradley and Taylor looked at combined spending on health and social services. By this measure, the U.S. was no longer at the top. The U.S. spent 29 percent of GDP on combined health and social services, while many Organisation for Economic Co-operation & Development (OECD) countries spent from 33 to 38 percent of GDP on the same set of services. In America, for every dollar spent on health care, we spend $.90 on social services; in the other OECD countries, the ratio is more like $1 on health care to $2 on social services.

Of course, these data don’t tell us anything absolute about cause and effect. We don’t know from the data if higher spending on social services resulted in lower health spending, or was caused by it. But it is telling that the countries used in this comparison all have better life expectancy and infant mortality statistics than the United States.

I was reminded about this while reading some recent articles, including Maurice Isserman’s op-ed in the New York Times, triggered by Charles Murray’s writings on the “culture of poverty” and critiques leveled at Michael Harrington (who was first to use that phrase in his book The Other America: Poverty in the United States, published 30 years ago this month).

The critiques have been compelling—and somewhat sad—about the use of the phrase “culture of poverty,” and how it has contributed to our disinvestment in poverty programs. As Maurice Isserman wrote in the Times, Harrington thought the term would spark investment in housing, medical care, education and jobs—and it did, to some degree, in Lyndon Johnson’s Great Society programs (though the programs were never as fully executed as Harrington had hoped). Harrington didn’t anticipate, however, that the behaviors he described as symptoms of poverty would come to be seen as causes.

As a result—and, perhaps because the description “war on poverty” implied the war would eventually end—we have disinvested in poverty programs over time. With under-investment come inevitable program failures, leading some to the conclusion the programs and ideas themselves don’t work. These conclusions are most unfortunate, because we know many of these programs do indeed work—when investments are appropriately targeted and focused (e.g., investments in high quality early childhood programs).

Perhaps the global data on combined health and social services spending can help policy makers rethink our investments in medical care. Wouldn’t it be exciting to discuss ways to reduce medical spending by reducing poverty, rather than chipping away at medical spending itself?

Maybe after the acrimonious debate and Supreme Court decision about the Affordable Care Act we can begin to have a broader discussion about health care in America. After all, the act is really mostly about our medical care system. And based on global data, when it comes to cost and health, medical care spending is clearly only part of the equation.