Bradley speaks on healthcare reform

On Monday, Feb. 6, President of the College Elizabeth Bradley discussed her 2013 book, “The American Healthcare Paradox: Why Spending More is Getting Us Less” in the Vassar library./ Courtesy of the Miscellany News

In the meditative evening glow of the Class of ’51 Reading Room, President of the College Elizabeth Bradley addressed a lecture about her book “The American Healthcare Paradox: Why Spending More is Getting Us Less” to the campus community on Monday, Feb. 5.

The book, which was co-authored with Lauren A. Taylor, was published in 2013. Taylor is currently a doctoral student at Harvard Business School, and previously studied public health at Yale University, where Bradley taught for many years before coming to Vassar last year (Harvard Business School Faculty and Research, “Lauren A. Taylor”).

Bradley and Taylor’s research identified a larger ratio of spending on professional healthcare to total health spending in the United States than in any other Organisation for Economic Co-operation and Development (OECD) country.

Stated in dollar terms, the differences between the U.S. and other OECD countries are quite drastic. Bradley clarified, “In the U.S., for every $1 spent on healthcare, about $0.90 is spent on social services. In the rest of the OECD, for every $1 spent on healthcare, about $2 is spent on social services.”

A literature review of the Journal of the American Medical Association and of other medical periodicals cited in Bradley’s study found that the most important social services for health measured in infant mortality, birth weight, premature death and life expectancy are supportive housing, nutritional assistance, community outreach and job training. Bradley estimates that these environmental and sociobehavioral factors determine 60 percent of health quality, compared to 20 percent for genetic factors and 20 percent for professional healthcare.

The United States’ overspending on professional healthcare arises from misplaced financial incentives and skewed medical models. Professor of Economics David Kennett stated, “The American healthcare system is characterized by very high physician salaries, even compared to countries with equivalent GNP per head and huge profit margins on drugs, because we can’t use countervailing powers in negotiation.”

Healthcare professionals and pharmaceutical companies have little financial incentive in the U.S. to change. While the U.S. spends more on professional healthcare than any other OECD country does, its total healthcare spending is just average. Bradley summarized, “The truth is, we’re spending in the middle and getting lousy outcomes.”

Putting the tradeoff in the U.S. between professional healthcare and social services into perspective, Bradley contrasted, “One emergency department visit is one month of rent. Two hospitalizations is one year of child care. Twenty MRIs is one social worker for a year. Sixty echocardiograms is one public school teacher for a year.” A key decision for policymakers in the United States is finding a way to strike the right balance in the American healthcare portfolio.

According to Bradley, American culture is a root cause of underfunding for social services in the United States. In Scandinavian countries where governments dedicate two-thirds of total health spending to social services, the World Values Survey reported that Scandinavians associate democracy with income equality, literacy and population health. Americans, on the other hand, associate democracy with national defense, neighborhood safety and economic growth.

Another factor contributing to this is that in the United States, there has historically been a divide between medical professionals and those working in social services.

Bradley explained, “One of the reasons why these groups don’t work well together is that they’re sociologically totally different. Medical models have been dominated by heavy science, started more male, there’s lots of degrees you need, it’s very elite. And social services, their history is totally different. Social services grew out of charity, or pity, or get your act together, it grew out of something that’s not a commodity that you would trade, mostly dominated by women.”

Bradley continued, “Americans tend to be kind of suspicious of social services … I think it’s hard to transfer funds from healthcare service to social serves we don’t trust.”

For this reason, developing the existing links between healthcare professionals and social workers may be one of the best ways to increase the impact of social services in the United States.

Bradley’s comments about increasing the role that social services play in public health were positively received by the audience. Emerita Professor of Political Science Mary Shanley suggested, “Listening to Bradley’s talk, I could think of many examples where her point about providing social services as a way of improving health would play out at the local level. Take housing. A drug addict is not going to find it easy to end their addiction if they don’t have access to rehab and then an affordable place to live. As a society, we need to provide support at the community level to break destructive cycles.”

Shanley has published extensively on American family structure and studied the impact of culture on societal wellbeing. A change in cultural perspectives on health and healthcare that sees social services as a holistic treatment of what Americans traditionally view as individual problems may have the far-reaching effects that Bradley proposes.

Likewise, Community Works Campaign Chair Karen Getter noted, “President Bradley presented her argument on providing health instead of healthcare in a clear and understandable manner. I found that her comments about using social services to extend health benefits resonated with my experience of local communities.”

Getter helps finance community projects by running fundraising campaigns and evaluating the best distribution of these funds to local initiatives. Community Works has supported nonprofit organizations such as Literacy Connections, Community Family Development and Ulster Immigrant Defense Network that provide the types of social services Bradley describes as crucial to improving public health in the United States.

Bradley said of some of these vital social services during her talk, “The WIC program has been with us for decades, it’s a really good investment … Meals on Wheels is a tremendous program, it keeps people out of nursing homes and saves a ton of money. And lastly, also case management and community outreach programs, which we have these all over the country, sometimes they’re done out of hospitals, sometimes they’re done out of United Way, sometimes out of churches, sometimes out of community vans, which really make a very large difference.”

The healthcare discussion also encouraged students concentrating in the physical sciences and preparing for medical careers to think more broadly about the social effects of their future work as practitioners.

Samanvaya Sharma ’18 reflected, “This talk, her book, and related books have made me question how doctors think about themselves as individuals practicing in their little community, not really connected to the outside world, the bigger systems. As a doctor, I now want to be engaged in the larger discourse on healthcare in the United States because that, at the end of the day, should also be a part of my goal rather than focusing on my personal practice.” From 2003 to 2012, the 2013 Vassar Fact Book recorded that each year between 29 and 49 students of the graduating class are admitted to medical school.

Other students focused on the implications of healthcare reform on the quality of care. Eli Schwamm ’19 responded, “By and large, smaller community-level healthcare is being replaced by larger conglomerates. I see a little bit of a conflict. On the one hand, large healthcare conglomerates are going to be less integrated in the local communities and have less social relationships with, for example, NGOs that work on housing or immigration. On the other hand, there is a large increase in interoperability among primary healthcare providers and specialists.” While there is ambiguity about final outcomes, changes to the healthcare industry often bring opportunities for improved services.

In a society that increasingly centralizes medical services, Bradley cautions against the exclusion of marginal populations from healthcare access and the national discourse on healthcare reform. Noting a flaw in healthcare access shared by Scandinavian countries and the United States, immigrant populations who do not fit a stereotypical national image often find themselves excluded from fully sharing in education, safety, job opportunity and ultimately health.

Emphasizing the importance of inclusion, Bradley argued, “One of the important things is being able to insure everybody, whether it’s through a lot of companies or through a single-payer system. If the United States could commit to insuring everybody, we would have an incentive to care for everybody’s health.”

In her research, Bradley made an effective use of statistical methods common to social science research, such as 10-year panel data analyzed for fixed-effects in a lagged model, to support her claims. Many of her findings on the positive effect that social services have on health in OECD countries were confirmed in the United States using data gathered from the 50 states.

Emeritus Professor of Astronomy Fred Chromey indicated, “I especially appreciated President Bradley’s application of statistical methods to a very complex social issue. I usu- ally see these methods applied in astrophysics and I was pleased to see the same methods in the context of healthcare policy. If you don’t have the data to back up your arguments, and if you don’t have a solid method for arguing from your data, you’re not going to be convincing. I think Bradley’s combination of quantitative and qualitative argument makes for a very convinc- ing piece of research.”

Despite significant results from OECD and state-level data sets, Bradley pointed out that quantifying the health benefits of a per-dollar increase in healthcare spending versus a per-dollar increase in social service spending remains an open research question.

But it seems clear that the healthcare paradox in America needs an answer. Bradley continued, “Changing our mental models, health and social services are different levers to achieving the same end.” Bradley and other audience members described this change as a paradigm shift in our collective understanding of health. Considering future developments in healthcare reform, she concluded, “It’s tough, it’s culture change … We have to know it’s a long haul with a lot of stuff.”

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