The American Health Care Paradox: Why Spending More Is Getting Us Less. Elizabeth H. Bradley and Lauren A. Taylor. 272 pp. New York, NY, PublicAffairs, 2013. ISBN 978-61309-209-9 (hbk.: alk. paper); 978-1-61309-210-5 (e-book).
Health care expenditures in the United States are projected to exceed $3 trillion per year, yet health outcomes continue to fall behind those of other developed countries. The American Health Care Paradox: Why Spending More Is Getting Us Less examines this phenomenon and argues that strategies to improve health in the United States have traditionally looked only at the health care system as the key driver of health and health outcomes. Authors Elizabeth Bradley and Lauren Taylor propose replacing the current paradigm, of investing directly into the medical system to improve health, with an increased focus on and investments in efforts that directly address social determinants of health, such as access to healthy food, recreational spaces, housing, and education.
As evidence for the importance that addressing social determinants of health improves health outcomes, the authors cast a broad net, gathering what they view as the best examples from abroad, with an emphasis on Scandinavian countries. The authors cite numerous studies, undercutting many of the most prominent arguments for the incommensurability of Scandinavian-style safety nets with American ideals of competition and radical individualism. In addition to citing potential foreign role models, the book also addresses approaches that emerged endogenously from the American context and warrant re-exploration, such as community health centers, innovations from within the Veteran’s Administration to provide veterans with shelter, and certain programs that combine assistance in finding housing and clinical care for the homeless.
Another crucial part of the book focuses on how the United States’ system of healthcare came to be in its current state, where expenditures continue to rise but health outcomes lag behind other developed countries. As Bradley and Taylor reveal, while a majority of other developed nations instituted universal health insurance as a safeguard for its citizens, in the United States the concept of health insurance and, consequently, health care spending, has been inextricably bound to employment, since its genesis. This has engendered a far dimmer perception of those who rely on the government and, therefore, indirectly on their neighbors, to pay for care. National distrust of government intervention and more recent trepidation surrounding the specter of socialism have only taken this perception further.
I think highly of Taylor’s and Bradley’s work; however, it must be understood as a starting point. If you are looking for a clear path forward, you will not find it in this book. This is not a critique of the work; it is a central facet of it. Each of the successful cases presented by the authors, whether on a local or national scale, is developed with a specific patient population in mind, eschewing the monolithic approaches that largely contributed to generating the present untenable state of health care in the first place.
New evidence is emerging that demonstrates that the broader health policy paradigm, advocated in this book, can meaningfully address shortcomings in our current system. An excellent example is the Harlem Children’s Zone (HCZ), a multi-dimensional, place-based approach to developing a healthy neighborhood and supporting the healthy development of children from birth to adulthood. The program focuses on children within a 100-block area in Central Harlem, where chronic disease and infant mortality rates exceed those in other sections of the city in conjunction with high rates of poverty and unemployment. Programs offered by the Children’s Zone include training and education of expectant parents, full-day pre-kindergarten, after-school and weekend community center programs, nutrition education, recreation options, and food services that provide healthy meals to students. In addition to health benefits, children who have gone through the program have also been determined to have a 92 percent matriculation rate into college, increasing their likelihood of breaking the cycle of poverty.
The American Health Care Paradox not only discusses why the United States fails miserably in its attempts to gain a good return on its health care investment, but also provides charts and tables distilling vast amounts of data.
This book blends accessibility and comprehensiveness on a deeply complex topic. In this era, when healthcare reform is at the forefront of current political discourse, Paradox is a valuable tool for educators, administrators, reformers, grant makers, and current and future physicians. It is a guide to understanding American medicine as it is now, and paths that may take us where we want to be.
Adil Menon, MBE '17, can be reached at BioethicsJournal (at) hms.harvard.edu.
 Schorn, Daniel. "The Harlem Children's Zone." CBS News. May 11, 2006. https://www.cbsnews.com/news/the-harlem-childrens-zone/.